right hemiparesis
29yo F ,homemaker , unmarried, hailing from chityal, who completed her bsc botany came with complaints of lethargy ,since 6 months.
history of presenting illness: patient was apparently asymptomatic 6 months back , when she started developing pedal edema on and off , subsided on taking rest and elevating limbs, easy fatiguability on doing daily chores like cooking, cleaning the house, which increased in intensity , causing her to take rest more often,doesnt resolve completely on rest.
not associated with ,chest pain, shortness of breath, giddiness,loss of appetite,weight loss.
past history:
12 years back , one afternoon during bathing she suddenly couldnt talk,or move her right upper and lowerlimb,with deviation of angle of mouth to the left ,upon which she made sounds , her mother who was nearby came to her aid ,and she was taken to hospital in nalgonda within an hour,and referred to gandhi hospital where she was admitted for 30 days,during which her speech returned and she was able to lift her upperlimb and walk without support.
she is now able to perform her daily activities, without any help, able to cook ,take bathe ,dress and undress, with difficulty in combing her hair and sweeping the house unaided.
this episode was not associated with blurring of vision, vomiting,headache,loss of consciousness, tingling ,numbness, swallowing difficulty.
she was given one prbc transfusion , started on asprin ,clopidogrel and prednisolone 10 mg which she used for 2 months, and dicontinued treatment on advice of local ayurvedic doctor,she did not follow up thereafter.
3 years back in 2019 she presented to Kamineni narketpally with complaints of painful swelling in the left side of the neck, for which usg guided fnac was done showing granuloma,started on ATT emperically and used for 6 months.
there was no history of fever,malaise,loss of weight, myalgias, loss of appetite,swelling in other areas,night sweats,chronic cough or shortness of breath.
menstrual history:regular 5/30,normal flow,no clots.
Family history:
Personal history:
General examination:
built: moderate
nourishment: moderate
Pallor:++
icterus-absent
lymphadenopathy:+
cyanosis:absent
clubbing:absent
koilinochya:absent
Pulse
Rate:104/minute
rythmn:normal
volume:
condition
of the vessel right left
Temporal + +
carotid. + +
subclavian. +. absent
brachial. +. absent
radial. +. absent
femoral. +. +
popliteal
posterior tibialis. +. +
dorsalis pedis. +. +
radio femoral delay. not present
bruit:. heard over abdominal aorta,left carotid
Blood pressure
upper limb 120/60 mm hg absent
lowerlimb 100 mmhg 100mmhg
Right/left handed person :initially right,then learnt to write with left hand since 12 years
education:bsc botany
Higher mental function
conscious
oriented
memory: intact
immediate
recent
remote
speech:
comprehension:+
fluency+
repetition+
reading+
writing+
naming objects+
cranial nerves. right. left
1-olfactory: present. present
2-visual acuity: 6/60
visual field:confrontation method:normal
colour vision:
3,4,6
eyelids :. normal. normal
positionnof eyeball at rest: normal. normal
extraocular movements :. normal. normal
pupil :size,shape normal. normal
direct and indirect
light reflex: present. present
5:
sensory:
touch: present. present
pain: present. present
temperature. present. present
motor:
side to side jaw movement normal
reflexes:
corneal. present. present
jaw jerk present.
7th-
motor-
frontalis. normal. normal
orbicularis oculus: normal. normal orbicularis oris: deviated to the left buccinator:. decreased. normal
sensory:
taste:. normal. normal
8th:
rinnie's. normal. normal
Weber's : no lateralization
9th,10th-
position of uvula:central
gag reflex
11th-
scm-. normal. normal
trapezius-. normal. normal
12th-
tongue: size,symmetry, deviation,tremor/fasiculation
motor:
attitude of limbs:
upper limb.
pronated and flexed. normal lowerlimb.
flexed at knee. normal
bulk:
arm:
forearm:
thigh:
leg:
tone: Right. left
upperlimb. increased. normal
lowerlimb. increased. normal
power:
1)Neck:
flexors:. normal. normal
extension: normal. normal
2) shoulder:
abduction: 4-/5. 5/5 adduction: 4-/5. 5/5
flexion:. 4-/5. 5/5 extension: 4-/5. 5/5
3)elbow:
flexion: normal Normal
extension: restricted Normal
4) wrist :
flexion: normal Normal
extension: restricted Normal
5) Trunk:
beevor's
abduction: gluteus
adduction:
6)knee:
flexion: hamstrings. 4-/5. 5/5
extrnsion: quadriceps 4-/5. 5/5
7) ankle:
plantar flexion: 4-/5. 5/5
dorsiflexion:. 4-/5. 5/5
Reflexes:
superficial
corneal. present. present
abdominal. present. present
plantar extensor. flexion
deep:
biceps +++ +
supinator +++ +
triceps +++ +
knee jerk +++ +
ankle jerk +++ +
Sensory:.
fine touch Normal Normal
joint position Normal Normal
vibration Normal Normal
crude touch Normal Normal
pain Normal Normal
temperature Normal Normal
Romberg's test: negative
cerebellum:
finger nose Normal Normal
finger finger Normal Normal
knee heal Normal Normal
rebound phenomenon negative
tandem walking present
Gait:
base:wide ,circumduction on the right
pace:normal
falling to sides:absent
hand swing:. absent present
turn:. normal
autonomic nervous system:normal
meningeal signs:absent
GHANDHI HOSPITAL,HYDERABAD
19 th january 2010
Previous reports
CT BRAIN(plain):
Hypoensity is seen in left capsulo ganglionic region and parigete temporal lobes with compression over left lateral ventricle.
IMPRESSION: ACUTE LEFT MCA INFARCT.
CAROTID DOPPLER:
RIGHT CCA:
shows diffuse circumferencial thickening 1.3m causing 30-40% in proximal and mid portion of cca. Causing obstruction and reduced flow velocities.
Distal cca and bulb,both internal and external carotid arteries show thrombosis causing obliteration of lumen 60%.with reduced flow velocities
LEFT CCA:
Filled echogenic material s/o thrombus from origin causing NEAR TOTAL obstruction and minimal color flow filling.
The thrombus extending Upto bulb,ICA and ECA causing partial obstruction and reduced flow velocity.
IMPRESSION: B/L CAROTID THROMBOSIS,DIFFUSE ON LEFT SIDE.
Impression:b/l vertebral arteries show NORMAL color flow filling and velocities.
CT AORTIC ANGIOGRAM:
-Narrowing seen at origin of INFERIOR MESENTERIC ARTERY.
-diffuse narrowing of right common carotid artery.
-There is narrowing of origin of left common carotid artery and no opacification of distal left common carotid artery
-Left subclavian artery is normal near the origin.There is diffuse narrowing of subclavian artery distal to origin of vertebral artery.
-E/o collateral seen in left supra scapular region.
-Irregular narrowing of thoracic aorta is seen.
IMPRESSION:Features are suggestive of AORTOARTERITIS.
KAMINENI HOSPITAL,NARKETPALLE
27th September 2019
Swelling over left posterior triangle of neck
CHEST X-RAY
IMPRESSION:MICROCYTIC HYPOCHROMIC ANEMIA 
Anisopoikilocytosis with microcytic hypochromic anemia,pencil forms,tear drop cells and few normocytes seen.
