A 35 year old woman with sudden altered sensorium, speech and right hemiparesis:
The complete case can be found here
ANATOMICAL REGION EFFECTED
it is a UMN lesion involving internal capsule on left which is producing dense hemiparesis
PATHOLOGY
a rosier score of 3 suggests a possible stroke,
an associated loss of conciousness indicates hemorrhagic stroke
INVESTIGATIONS TO CONFIRM DIAGNOSIS
Computed tomography (CT) scanning is the mainstay of emergency stroke imaging.
MRI is required as this is a delayed presentation
carotid doppler should be done for information can be provided about the degree of arterial stenosis and the presence of ulcerated plaques.
lumbar punture is required to rule out subarachnoid hemorrhage after unsertain imaging
blood glucose, triglycerides, ESR
presenting problems
Vomitings ( 3 episodes ) 6 days ago followed by altered sensorium.
No h/o
Trauma,
fever with cough and cold
chest pain
Known case of Tuberculosis 4 yrs back for which she took anti tubercular treatment for 6 months.
No other significant past or family history.
EXAMINATION:
Pallor- present
Mild dehydration and malnutrition present.
Doll’s eye - positive
Pulse- 110 bpm
RR- 20 cycles/min
BP- 100/60 mmhg
RBS- 96 %
CVS , Respiratory and GI systems are normal on examination.
CVS EXAMINATION:
Higher mental function- pt is unconscious and stuporous.
Cranial Nerves:
1st and 2ns - not elicited
3rd 4th 6th - normal
5th-Motor - not elicited
Sensory- not elicited
Corneal and conjunctival reflex- normal
7th - nasolabial fold- N and no deviation of mouth.
Corneal and conjunctival reflex- normal
Secretomotor- moistness of tongue and eyes- N
Sensory- not elicited
8th - Renne’s ans Weber’s- not elicited
9th and 10th- uvula centrally placed
Gag reflex present
11th- trapezius and sternocliedomastoid - not elicited
12th- tongue tone normal
No wasting, no deviation.
Motor system:
Decreased tone in right upper and lower limbs.
Power -not elicited in rt UL and LL. 3/4 in left UU and LL
Reflexs present
Primitive reflex- absent
Involuntary movements- absent
Left lower limb shows continuous and intermittent movements.
Sensory system- not elicited.
Pain in all four limbs
Meningeal signs- neck stiffness present
•Cerebellar signs- absent
INVESTIGATIONS:
MRI : CAPSULOGANGLIONIC HEMORRHAGE.
COURSE IN HOSPITAL:
After admission to ICU:
high grade fever with leukocytosis - managed with IV antibiotics.
mass lesion ans hematoma
recovered from coma spontaneously and mobilised herself slowly with persistent neurological deficits.
still no speech due to affection of Broca’s area.
Psychiatry referral suggested in view of cognitive and higher mental functions.
According to informent :-
C/o not talking only responding at times.
Stressors(financial, family, personal)
Crying spells + low mood+ she was active at work
GAB patient is lying on bed unable to move her right arm and leg
ETEC +, built not sustained
PMA decreased
Rapport could not be established
SPEECH:not uttering words but responding to sounds at times non verbal communication +at times though a bit slow
AFFECT: dysphoric
Further MSE could not be elicited , Orientation could not be assessed
Patient power gradually improved from 0/5 on right side to 3/5 and on left side improved for 3/5 to 4/5.
DIAGNOSIS:
Cardiovascular accident causing right sided Hemiplegia-
Acute Hemorrhage involving left corona radiata and Lentiform nucleus, internal capsule with intraventricular extension.
Secondary to 1) AV malformations??
2) Underlying mass lesion with old pulmonary koch’s
TREATMENT:
• inj amikacin
• inj ceftrioxone
• tab pan top
• tab Zofer
• tab paracetamol
• b complex
• vitals monitoring
• DVT stocking, air bed and constant change of position
• tab fluoxetin
• chest , upper limb, lower limb physiotherapy
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