Case report

Division A

Neurology

AYUB ABDIRIZAK MOHAMED

180110050
Group PBL 5
Personal History:
A right-handed 64-year-old-male patient named Mohsen Mostafa from
Mansoura working as a mechanic, married and has 3 offspring; youngest is 31
years old and no special habits of medical importance.

Complaint:
Weakness of right upper and lower limbs with acute onset, regressive course
and 10 days ago

Family History:
No family history of consanguinity. No family history of the same neurological
condition. No family history of other neuropsychiatric disorder.

Past History:
No past history of trauma or fever related to the onset. Positive past history of
similar attack 1 year ago. Positive history of hypertension and diabetes. No past
history of TB or Syphilis. No past history of otitis media. No past history of
ischemic heart disease. No past history of surgical operation. Positive history of
drug intake for hypertension and diabetes; concor 10 plus ( bisoprolol +
hydroclorothiazide) and amaryl ( Glimepiride).

Present History:
Conditon started 10 days ago with acute onset and regresive course of
paresis in right side of the body in both upper and lower limb poximal as
distal simultaneously associated with hemihypothesia in the side affectd.
Patient walks with unilateral support.
No increasing intracranial tension as headache, blurred vision or
vomiting. No other cranial nerves affection except facial nerve; patient able
to close his eyes firmly but there is accumulation of food and drooping of
the angel of the mouth. No visual disturbance like: hemianopia, sudden or
reversible loss. No fecal incontinence or urinary sphincteric affection. No
loss of consciousness or faints. No basilar artery affection like vertigo,
imbalance or drop attacks. No symptoms suggestive of meningeal irritation.
No other systems affection.
On gereral examination:
Appearance: The patient appeared ill. Had an average build. Good nutritional
state. Normal complexion. He uses unilateral support to walk and wheelchair.
Vital signs:
Pulse: 92 beats per minute; normal rate, regular rhythm, average force, tension
and volume, with no special characters, equal in both arms, no radio-femoral delay
with good vessel wall status.
Blood pressure: 130/85 mmHg
Temperature: 37.2°C

Respiratory rate: 16 breaths per minute

Head & neck examination: NAD; Normal head size. No congested veins.
Normal hair and facial appearance. Normal Tracheal examination. Normal non
palpable lymph nodes. Normal thyroid gland.

Upper limb examination: NAD; No muscle wasting or skeletal deformity.

No vasomotor changes like cyanosis, coldness, abnormal sweating. Normal
nailbeds and no pallor or clubbing. Normal hair and skin luster i.e. No trophic
changes.

Lower limb examination: NAD; No edema LL. No varicose veins. No

vasomotor or trophic changes. No muscular wasting or skeletal deformities. No
ulcers. No bed sores. Palpable pulse.

Abdominal examination: NAD;

By inspection, no organomegaly. No epigastric pulsations. Normal flat
abdomen without ascitis. No diviculation of recti. Normal pubic hair
distribution. Normal acute subcostal angle. Normal inverted umbilicus with no
discoloration. No scars or strech marks are found. No dilated or visible veins.
By palpation, superfecial and deep palpations revealed no hepatomegaly or
spleenomegaly. No hepatic or epigastric pulsation.
By percussion, normal resonance percousion; no ascitis and normal resonant
Troub’s space.
By auscultation, no bruit and normal bowel sound.
Chest examination: NAD;
By inspection, normal precordim, no scars, no visible suprasternal, parasternal or
epigastric pulsation and no vesible veins or any bulge. Normal abdomino-thoracic
respiration.
By palpation, apical pulse is regular rhythm and normal rate, localized norally,
with systolic pulge, no thrill, no pulse deficit and no special character. No other
papable pulsations. No palpable thrills. There isn’t sites of local tenderness or
crepitations.
By percussion, there are normal heart borders without dullness outside. Normal
bare area. Normal resinant lung. similar sounds on both sides of the same
region.
By auscultation, Normal heart sounds with no added sounds and localized apex at
the left 5th intercostal space in the midclavicular line. Both lung fields are clear to
auscultation with no wheezes nor crepitations.

On neurological examination:
Examination of Intellectual Functions:
The patient is fully conscious, oriented to time, place, and persons with average
mood and affect, cooperative, of average intelligence, with no vivid illusions,
delusions or hallucinations. GCS is 15 Speech: Dysarthria slurred speech.
Cranial nerve examination:
• I, II: NAD; Normal olfaction, visual acuity, visual field, no color
blindness.
• III, IV, VI: NAD; No ptosis, normal pupil equal on both sides, no squint,
normal extra ocular muscle movement in all directions, normal direct and
consensual light reflex, normal accommodation reflex.
• V: NAD; Intact sensation in both sides of the face. Normal power of
muscles of mastication. Normal jaw reflex. Normal corneal and
conjunctival reflex.
• VII: There is UMNL of right facial nerve; by inspection the patient has
obletrated nasolabial fold and drooping of the right angel of the mouth.
There is normal ability to close eye frimly.
• VIII: NAD; Normal hearing acuity, no vertigo.
• IX, X: NAD; The uvula is centralized, Normal palatal and pharyngeal
reflex.
 • XI: NAD; The patient can raise the shoulder against resistance. The
patient can turn his chin against resistance.
• XII: NAD; there is no tongue deviation, fasciculation or wasting
Motor assessment:
Muscle state: by inspection, o Muscle bulk: NAD; Neither

wasting nor hypertrophy.

o Abnormal contractions: positive fasciculations o Involntary
movement: NAD; no tremors, chorea or dystonia o Posture:
semi-flexed UL & extended LL. o Trophic changes: NAD

Muscle tone: on examination there were hypertonia (spasticity) in right upper

and lover limbs and normal tone in left side.
Muscle power: on examination there was weakness in the right side; score 1 in
MRC scale
Reflexes: on examination there were o Deep: exagerated deep reflexes (+3) in
the right side compared to the left side o Superficial: +ve babinski sign
without fanning of toes. Lost abdominal reflexes.

Coordination assessment:
Examination revealed intact coordination with no decomposition of movement,
no kinetic intension tremors and no dysmetria and with normal equilibrium.

Sensory assessment: Mild hemihypothesia and intact deep sensation

Examination of the back &spine: No tenderness, deformity,

swelling, erythematous areas or scars.

Examination of the trophic & vasomotor changes: NAD

meningeal irritation: No specific signs detected.
Gait examination: circumduction gait.
Differential diagnosis:
 Ischemic stroke
 Hemarragic stroke
 Embolis
 Enchephalitis
 Tumor

Invstigations:
• Non contrast CT scan
• Contrast CT scan
• Complete Blood Count (CBC)
• Bleeding profile
• Kidney and liver functions
• ECG
• Echocardiography
CT scan:
CBC:
Bleeding profile:

Kidney and liver functions:

ECG:
Echo:
Further investigations:
 MRI (T1-T2)
 MRA
 Angiography

provisional diagnosis:
Acute right sided capsular ischemic hemiplegia.

Suggested plan of treatment and management:

 The patient took within the time window:

Tissue plasminogen activator (TPA): 0.9 mg/kg over 60 min

 Suggested treatment:
1. Antiplatelet (Aspirin)
2. Anticoagulant (low molecular weight heparin)
3. Mechanical Thrombectomy
4. Continue the medication for hypertension and diabetes
5. Physiotherapy