CASE SCENARIO: You are a neurologist at a major urban hospital.

A 63 year-old African-American female

with a history of hypertension is brought to you for your neurological assessment. She is currently taking
verapamil (Calan) "when she remembers" and has a blood pressure of 139/107. The patient complains
of both motor and sensory problems that began several days ago. A series of cognitive, sensory and
motor tests reveal the following signs and symptoms:

The patient has completely lost the perception of the somatic senses from the right side of her jaw, face
and tongue. There is only minor diminishment in somatosensation from her right hand and lower arm.
However, even though the patient recognizes she has an object in her right hand by touch, she has
almost no ability to identify objects by touch when they are hidden from sight. Sensation in her left arm,
torso and both legs is unaffected.

The patient experiences flaccid (non-contracting) paralysis in the muscles on the right side of her jaw
and face. Movements of her right hand are hesitant and uncoordinated - she can no longer play the
piano or type with her right hand. She can no longer move her right ring finger at all. Activity and
coordination of other muscle groups appear normal.

The patient understands written and spoken words and can read and write normally. However, his
speech is labored and her enunciation is severely impaired.

Your task is to evaluate the patient and write a case summary. This summary should include a brief
description of her major symptoms and the patient's diagnosis. This diagnosis should include a brief
description of the problem and its location. The potential causes of this problem and whether the
problem will improve with treatment and time.
Neurologist: Kiana P. Ramosa

A CASE STUDY ANALYSIS

Clinical Medical Summary

PATIENT’S INFORMATION

Name: Unknown Date of Birth: N/A

Age: 63 Years old Marital Status: N/A

Sex: Female Address: N/A

Nationality(s): African-American

Current medication: Verapamil (Calan)

Blood pressure: 139/107

Medical History: Hypertension Stage 2

History of present illness:

The patient is a 63 year old woman with a history of hypertension who complains of both motor
and sensory problems that began several days ago. The patient has completely lost the perception
of the somatic senses from the right side of her jaw, face and tongue. There is only minor diminishment
in somatosensation from her right hand and lower arm. The patient has almost no ability to identify
objects by touch when they are hidden from sight. Sensation in her left arm, torsi and both legs
is unaffected. The patient experiences flaccid (non-contracting) paralysis in the muscles on the
right side of her jaw and face. Movements of her right hand are hesitant and uncoordinated -
she can no longer play the piano or type with her right hand. She can no longer move her right
ring finger at all.
Past medical history: Hypertension
Medications: The patient is currently taking verapamil (Calan) "when she remembers"
Assessment:
In summary, a 63 year old woman patient has a right side facial paralysis that complains of both
motor and sensory problems. The patient blood pressure is 139/107 which is a stage 2 of
hypertension that can lead to stroke and heart disease. The major symptoms of a patient are
sensory impulses which include the loss of Stereognosis and loss of somatic sensation over right
side of face jaw and tongue. Speech is labour red from the above symptoms, I can conclude
that the patient may have a stroke. Since the patient has a history of hypertension and has a
Right-sided weakness or paralysis and sensory impairment, the possible type of stroke that she
has is left hemispheric stroke of ischemic stroke. Left hemispheric stroke of ischemic occurs
when the blood cannot flow to the left side of the brain that causes blood clot. It can lead to
hemorrhagic, if the blood clot will burst. But since the patient is alive and has symptoms for the
past few days, the type of stroke that she has is ischemic stroke, and that is only a blood clot in
her brain. This type of stroke can also be related to hypertension. Based also on the
neurological problems of the patient, it is given that she is suffering from a type of stroke that
caused by a blood clot within the brain tissue itself. The resulting pressure and blood flow
interruption cause damage that may include facial paralysis; it is the inability to move the
muscles of the face on one or both sides. The damage of the patient’s brain is on the left
hemisphere since she lost her senses on the right side and causes right-side paralysis.
Specifically, it is called the left hemispheric stroke. The patient also stated that she is currently
taking verapamil (Calan) “when she remembers”. She is unsure and the possible cause is a
cognitive dysfunction which is memory loss. That is one of the complications of the left
hemispheric stroke of ischemic stroke. Left hemispheric stroke is located on the left side of our
brain and has damage in the cerebrum, which is the cerebrum is responsible for cognitive
functions. Left hemispheric stroke (ischemic) increases the risk of a person that is 55 years old
above and with high blood pressure. It states that the patient is at risk of this type of stroke.
Due to the brain nerve damage, the patient can also have a Bell’s palsy which is the common
result of flaccid paralysis. Bell’s palsy or facial paralysis is also experienced by the patient. She
lost the perception of somatic senses from the right side of the jaw, face and tongue which are
the symptoms of having a bell’s palsy. The exact cause of Bell’s palsy is unknown but it can
sometimes relate to high blood pressure, flaccid paralysis or any nerve damage that can
possibly connected to the brain.
Diagnosis
Left hemispheric stroke
Type: Ischemic stroke
Flaccid paralysis is experienced by the patient
Can possibly have Bell’s palsy
Stroke can be based on a medical history of the patient and a physical exam, it can identify
whether it is left hemispheric stroke or right hemispheric stroke. A stroke is suspected to the
patient, conducting a magnetic resonance imaging (MRI) or computed tomography (CT) scans
can help to determine whether the stroke is caused by a clot (ischemic) or a bleeding
(hemorrhagic). Angiogram also is used to look at the heart and its blood supply, and the other
are Magnetic resonance angiography (MRA) and Doppler ultrasound.

The major symptom

The major symptom of a patient is sensory impulses which include the loss of Stereognosis and
loss of somatic sensation over right side of face jaw and tongue.

Location of the symptoms

Flaccid paralysis damaged located at the lower motor neurons.
Ischemic stroke occurs when an artery that supplies blood to the brain is blocked by a blood
clot or fatty build up, called plaque. This blockage can appear at the neck or in the skull. Clots
usually start in the heart and travel through the circulatory system. The left hemispheric stroke
is located at the cerebrum of the brain.
Bell’s palsy is a condition results from damage located to the facial nerve (the 7th cranial
nerve).

Treatment
Surgery can help to relieve pressure on her brain and repair damage arteries. The two surgeries
for ischemic stroke are embolectomy, it is a tube is passed through blood to remove a clot or
deliver medicine to break it up and a vertebrobasilar angioplasty and stenting , it is a major
artery to the brain is widened and a mesh tube is left in place to help keep it open. Also she
needs to control her blood pressure; it is the first key step for her recovery. For an ischemic
stroke, medicine may be given to dissolve clots and prevent new ones from forming thin blood.
Without the intervention of a physical therapy and a speech therapy, she cannot initiate any
muscle movements on the affected side of their body or able to restore language-related
impairment. If this continues for long enough and if her muscles don’t work, the unused
muscles become much weaker, and begin to atrophy. Occupational therapy may help regain
certain skills and independence by practicing and modifying everyday activities. Long –term
treatment are needed. Maintaining also her high blood pressure and healthy lifestyle can
prevent this illness.

Recovery Time

The patient’s speech, cognitive, motor and sensory skills can steadily be recovered. Since 1995,
there are 70 % of survival rate of stroke due to improvements of blood pressure, advancements
of technology that are use to diagnosis of stroke, maintain medicine , possible surgery and also
because of some therapy. The rapid recovery time of a stroke is about three to four months and
many senior specifically in ischemic stroke can recover in two to four months after the stroke,
but some of the speech, cognitive, motor and sensory skills can take longer time to be fully
recovered.