Institute of Health, Faculty of Medical Sciences PBL case for Medical students.

Module Name: Nervous system

Problem: one side body weakness
Part-I: Trigger
A 65 years old teacher from Jimma town was presented to JUMC with the compliant of
right side body weakness of one day duration. Associated with this he has speech
difficulty and headache.
 Institute of Health, Faculty of Medical Sciences PBL case for Medical students.

Part-II: HPI
He had history of intermittent headache one month prior to the current compliant at
which time he fall down on the ground by losing his balance while he went out of school
on the way to home. He has trouble in grabbing his shoe tie and unable to walk properly
after falls down.
He had trouble in concentrating and forgets the names of his children.
He has no prior history of Hypertension or diabetes except he had one episode of high
blood pressure 5 years back which was measured after heavy exercise.
He is a known HIV patient taking antiretroviral drugs.
He has occasional muscle pain and joint pain
No previous history of muscle weakness
One year ago he was hit by a car after which he got treated and told to be cured.
Six weeks ago he had loss of vision in the morning for about 15minutes which improved
by itself without any treatment
No history of fever
He smokes cigarette for the last 30 years.
 Institute of Health, Faculty of Medical Sciences PBL case for Medical students.

Part III: Physical examination

General Appearance: He has left side facial weakness and gait abnormality
V/S: BP: 180/110 mmHg, HR: 63 beat/minute not full volume, RR: 22 breath/minutes, T⸰=37
℃
Head, Ear, Eye, Nose and Throat
o Has mild contusion and abrasion on the left side of the head
o Pink conjunctiva and non icteric sclera
o Unable to close the left eye
o Has loss of naso-labial fold on the left side of the face
o Unable to puff his check and unable to drink or chew on the left side
o The face moves towards the right while smiling
o Excessive drowning of saliva
Lymphoglandular System
o Cervical lymph node which is solitary measures 0.5 cm by 0.5 cm
o Axillary and inguinal lymph nodes also measure 0.5 cm by 0.5 cm
Respiratory System
o Clear and resonant
o Bilateral and equal air entry
Cardiovascular System
o S1 and S2 well heard, no murmur
o S4 heard
Abdomen
o Full and moves with respiration
o Big tummy with central obesity
o No enlarged intra-abdominal mass and no pain on touching
o Bowel movement is 10 per minute
Genitourinary System
o No flank pain during touching
Musculoskeletal and Integumentary System
o No scar and skin discoloration
 Institute of Health, Faculty of Medical Sciences PBL case for Medical students.

o No joint swelling or tenderness

o Capillary refill is less than 1 sec
Central Nervous System
 Confused not oriented to time, place and person
 Motor 1/6 on the right extremity and 6/6 on the left extremity
 Sensory 2/5 on the right extremity and 6/6 on the left extremity
 Verbal response 3/4
 Slurred speech
 Institute of Health, Faculty of Medical Sciences PBL case for Medical students.

Part-IV: Laboratory Investigations

Parameter Result
1. CBC RBC 5.2million cells/µL

Hematocrit (Hct) 43.8%

Hemoglobin (Hbg) 14.6g /dl

WBC WBC 8,500cells/mm3

Neutrophils 13,500 cells/mm3
Lymphocytes 4000 per mm3
Monocytes 600 cells/mm3
Eosinophil 300 cells/mm3
Basophils 100 cells/mm3
2. LFT AST 32IU/L
ALT 28IU/L
ALP 40IU/L
TBIL 0.9mg/dl
3. RFT BUN 14mg/dl
Creatinine (CR) 0.8mg/dl
4. Blood RBS 150mg/dl
sugar level HgA1C 6.5g/dl
5. ESR 22mm/hr
6. Opening pressure Normal
Cerebrospinal
Protien: 53mg/100ml
fluid
Glucose: 64mg/100ml
WBC 3
RBC: 0
7. Lipid LDL 135mg/dl
profile
HDL 39mg/dl
Total Cholesterol 250mg/dl

Imaging
 Institute of Health, Faculty of Medical Sciences PBL case for Medical students.

Chest x-ray
 No tracheal deviation, No Hilar lymphadenopathy and retrosternal mass extension
 Left heart border is displaced leftward, inferiorly and posteriorly. There is rounding
of cardiac apex.
Echo
 Left ventricular hypertrophy
CT scan
 No mass, collection but there was blood clot in the subdural space
MRI
 Brain parenchyma is normal
 No ring enhancement on contrast
 There is Subdural hemorrhage on T1W1
 Institute of Health, Faculty of Medical Sciences PBL case for Medical students.

Part five: – Case summary/ Synthesis /validation of key point’s regarding the
specific cased to be approached /solved (for Tutors use only)

 Patient problem: one side body weakness

C/C : Right side body weakness

 Associated S/S: speech difficulty and headache

 Relevant information( Hx, PE and lab findings)
 Hx:
He had history of intermittent headache one month prior
Falling down in the afternoon by losing his balance
He has trouble in grabbing his shoe tie and unable to walk properly after falls down.
He had trouble in concentrating and forgets the names of his children.
He had one episode of high blood pressure 5 years back
Six weeks ago he had loss of vision in the morning for about 15minutes which improved
by itself without any treatment (TIA)
He smokes cigarette for the last 30 years.
 Key PE findings :
V/S: BP: 180/110 mmHg, HR: 63 beat/minute not full volume
Head, Ear, Eye, Nose and Throat
o Unable to close the left eye
o Has loss of naso-labial fold on the left side of the face
o Unable to puff his check and unable to drink or chew on the left side
o The face moves towards the right while smiling
o Excessive drowning of saliva
Cardiovascular System
o S1 and S2 well heard, no murmur
o S4 heard
Abdomen
o Big tummy with central obesity
Central Nervous System
 Institute of Health, Faculty of Medical Sciences PBL case for Medical students.

 Confused not oriented to time, place and person

 Motor 1/6 on the right extremity and 6/6 on the left extremity
 Sensory 2/5 on the right extremity and 6/6 on the left extremity
 Verbal response 3/4
 Slurred speech
 Key Lab investigations findings :
o RBS: 150mg/dl
o HgA1C: 6.5g/dl
o Lipid Profile: LDL: 135mg/dl; HDL: 39mg/dl; Total cholesterol: 150mg/dl
Key radiographic examination findings
Chest x-ray
 Left heart border is displaced leftward, inferiorly and posteriorly.
There is rounding of cardiac apex.
Echo
 Left ventricular hypertrophy
CT scan
 Blood clot in the subdural space
MRI
 There is Subdural hemorrhage on T1W1

 DX: Hemorrhagic stroke

 Management Principles

 Medical treatment
o Anti Hypertensives
o Aspirin/ Statin
 Surgery
o Surgical evacuation of subdural heamatoma.
 Rehabilitation
o Physiotherapy
o Diet modification
o Exercise