Case presentation

1. CASE PRESENTATION
By - Dr Pranabes Chakraborti
(post graduate student, 2nd year)
Moderator –Dr Sagar Samrat Debbarma
(PGT 3rd Year)

2. Particulars of the Patient
Name- Mr. Chitta Ranjan Deb
Age- 57 years
Sex -Male
Religion–Hindu
Occupation- Contractor
Address – Kamalpur
DOA -25/11/2019
DOE- 25/11/2019 & 26/11/2019

3. CHIEF COMPLAINT
Weakness over the right side of the body – 3 days.
Slurring of speech - 3 days.

4. H/O PRESENT ILLNESS
The patient was apparently alright 3 days ago. In 25/11/2019, 4:00 AM patient went to bathroom after
getting up from sleep and had episode of reeling of head accompanied by fall but fall on ground
was prevented as his wife supported him. After that he was taken to bedroom and made to lie
down on bed. It is then when he felt weakness in his right hand and right leg while trying to move
his limbs. Weakness started simultaneously in both upper and lower limbs. It was sudden in onset,
progressive in nature and completed within half an hour. He was eventually taken to the local
hospital by his family members. At the same time he also developed slurring of speech which was
quickly followed by inability to speak properly and deviation of angle of mouth. There was no
history of dribbling of saliva. He also had an episode of involuntary passing of urine at the local
hospital.

5. H/O PRESENT ILLNESS
It was not associated with any h/o loss of consciousness/ jerky
movements of body/ headache/ fever/ nausea/ vomiting/ vertigo.
No h/o altered vision/urinary retention. No h/o chest pain/shortness of
breath/ palpitations.

6. Past History
He is known Hypertensive for last 8 years under amlodipine 5mg (irregular
medication). Patient did not take anti hypertensive for 4 days before the event.
There is no history of diabetes.
No other significant history

7. Family History
4 family members–himself, his wife, 1 son and a daughter.
Father died due to stroke at the age of 65 years , he
was a diagnosed hypertensive.

8. PERSONAL HISTORY
Mixed diet
Non alcoholic
Non smoker
Bowel and bladder habits – Normal.

9. DRUG & ALLERGY HISTORY
• No h/o of allergy to any drug or food substances as such.

10. SOCIOECONOMIC HISTORY
• Average Monthly family income Rs 50,000.
• Belongs to middle socioeconomic class

11. SUMMARY
An 57 years old hypertensive, non-diabetic male with a family history of stroke
came with complaints of sudden onset right sided weakness , slurring of
speech and deviation of angle of mouth for last 3 days.

12. DIFFERENTIAL DIAGNOSIS
 Haemorrhagic stroke
Ischemic Stroke
ICSOL

13. GENERAL EXAMINATION
 Conscious, oriented to time, place and person.
 Lying in supine position.
 No pallor, cyanosis, icterus, clubbing, edema, generalized lymphadenopathy
 Pulse rate - 68 bpm regular rhythm, normal volume and character, bilaterally
symmetrical, no radio femoral delay & all peripheral pulses are felt well. Vessel walls were
palpable in almost all the peripheral arteries.
 BP - 140/90 mmHg measured in both right and left upper limb in supine position
 RR – 14 pm, abdominothoracic type
 No engorged neck veins or thyromegaly
 JVP not raised
 No carotid bruit

14. EXAMINATION OF CNS
Higher mental functions -
- Conscious, oriented to time, place and person.
- Right handed.
- Co-operative
- GCS – 15/15 (E = 4, V = 5, M = 6)
- Memory , intelligence – normal.
- Speech – slurred, dysphonic.

15. CRANIAL NERVE EXAMINATION
Cranial nerve Right Left
Olfactory Intact
Optic Nerve Intact
Occulomotor Intact
Trochlear Intact
Trigeminal Intact
Abducens Intact
Facial Lower half of the face - involved Intact
Vestibulocochlear Intact
Glossopharyngeal &
Vagus
Uvula deviated to right and left sided palatal paralysis.
Spinal accessory Intact
Hypoglossal Tongue deviated to right.

16. Motor system examination
No abnormal movements/fasciculations seen
Muscle bulk –
• No atrophy, symmetric
Muscle tone –
• Normal tone in left upper and lower limb
• normal tone in right upper and lower limb

17. Upper limb
Muscle Power
Right Left
Shoulder Abd 0/5 5/5
Add 0/5 5/5
Elbow Flx 0/5 5/5
Ext 0/5 5/5
Forearm Sup 0/5 5/5
Pron 0/5 5/5
Wrist
Ext 0/5 5/5
Flex 0/5 5/5
Abd 0/5 5/5
Add 0/5 5/5
Thumb
Abd 0/5 5/5
Add 0/5 5/5
Opp 0/5 5/5
Finger Lumb. 0/5 5/5
Interr. 0/5 5/5

18. Lower limb
Right Left
Hip Flx 0/5 5/5
Ext 0/5 5/5
Add 0/5 5/5
Abd 0/5 5/5
Knee Flx 0/5 5/5
Ext 0/5 5/5
Ankle Dorsi Flx 0/5 5/5
Plant. Flx 0/5 5/5
Ext. Hall. Dorsi Flx 0/5 5/5
Plant. Flx 0/5 5/5
Ext Dig
Lo.
Dorsi Flx 0/5 5/5
Plant Flx 0/5 5/5
Flx Dig Lo. Dorsi Flx 0/5 5/5
Plant Flx 0/5 5/5

19. Reflex
Superficial Right Left
Abdominal Present Present
Plantar extensor Plantar Flexion
Deep
Biceps 2/4 2/4
Triceps 2/4 2/4
Supinator 2/4 2/4
Knee 3/4 2/4
Ankle 3/4 2/4

20. Sensory functions
BOTH UPPER AND LOWER LIMB – INTACT SENSORY FUNCTION

21.  Cerebellar functions: Could not be assessed.
 Gait : could not be assessed.
 Autonomic nervous system examinations: not done.
 Cranium & spine: normal
 No meningeal signs observed

22. CVS Examination
Chest bilaterally symmetrical
No visible pulsation
No thrill
Apical impulse 5 left ICS at left mid clavicular line
 S1 S2 Heard
No murmur audible
No added sound

23. Respiratory System Examination
Trachea in midline
Normal vocal resonance and vocal fremitus on both side of chest
Normal vesicular breath sounds heard
No added sounds heard

24. Examination of Abdomen
Abdomen moves equally with respiration
Umbilicus in midline, inverted, transversely slit
No visible pulsation or venous prominence
Hernial orifices normal
No organomegaly
Bowel sounds heard

25. SUMMARY
• An 57 yrs hypertensive presented with right sided weakness with
deviation of face towards left side & slurring of speech for last 3
days.
• On examination – he was conscious, co-operative with UMN type
of right VII, IX, Xand XIth nerve palsy with right sided weakness &
exaggerated reflexes.

26. PROVISIONAL DIAGNOSIS
 Haemorrhagic stroke
 Ischemic stroke
 ICSOL

27. Investigations
Haemoglobin -15.6gm/dl
TLC 8000/cum m
Neutrophils 78%, lymphocytes 20%, Monocyte 01,
Eosinophil 01
Platelet count-2.1 lacs/cumm
RBS- 91 mg/dl
Urea 32
Serum creatinine 1.4
Na – 140meq/l, K – 3.2meq/l

28. HbsAg Negative
Anti HCV Negative
ECG – Sinus rhythm , no significant changes

29. NCCT brain : Acute ICH involving posterior limb of
left internal capsule with perilesional edema
compressing the left thalamus and basal ganglia.

30. DIAGNOSIS
CVA right sided complete hemiplegia due to acute intra cerebral
hemorrhage in posterior limb of left
internal capsule, basal ganglia & periventricular region due to
involvement of branches of MCA. Known
hypertensive & GCS-15/15 .

31. THANK YOU