Case Presentaion: Souvik Paul BPT 3 Year Nopany Institute of Healthcare Studies

CASE PRESENTAION
SOUVIK PAUL
BPT 3RD YEAR
NOPANY INSTITUTE OF HEALTHCARE STUDIES

DEMOGRAPHIC DATA:
 PATIENT NAME : Mrs. Sampa Dey

 AGE : 55 years
 SEX : Female
 OCCUPATION : House wife
 ADDRESS : Girish Park, Kolkata
 DATE OF
EXAMINATION : 17.05.2018
 HAND DOMINANCE : Right
CHIEF COMPLAINTS
 Patient is having difficulty in gripping and releasing object

with left hand
 She is also having balance problem during walking

HISTORY
 HISTORY OF PRESENT ILLNESS: Right hemispheric TIA in February 2017,

with left facial droop, resolved in 5-10 mins and, then developed
progressive spastic left hemiparesis from March 2017 onwards
 HISTORY OF PAST ILLNESS: Patient is a known case of hypertension. Patient
has migraine like headache during college days.
 MEDICAL HISTORY:
 FAMILY HISTORY: No family history of stroke.

SOCIAL HISTORY:
SOCIAL SITUATION:
SUPPORT STRUCTURE:
ACCOMODATION:
ACTIVITIES:
NORMAL DAILY ROUTINE:
EMPLOIMENT :
LEISURE ACTIVITIES:
 MOBILITY:
GENERAL:
INDOOR:
OUTDOOR:
STEPS AND STAIRES :
FALLS HISTORY :
OBSERVATION
 BODY BUILT : Mesomorphic

 POSTURE: Right Shoulder depressed. Fingers of Left hand are flexed.
 GAIT : Circumductory Gait

POSTURE
 Right Shoulder depressed. Fingers of Left

hand are flexed.
EXAMINATION
VITAL SIGNS
 Blood Pressure : 140/90 mm hg on 04th May 2018 at 3:05 pm
 Heart rate : 78 bpm

ON EXAMINATION
HIGHER MENTAL FUNCTION

 Patient is conscious alert and cooperative
 Memory : STM- normal
LTM- normal
 APPEARANCE &BEHAVIOUR : Extrovert type of behaviour
 EMOTIONAL STATE: Stable
 ORIENTATION IN TIME SPACE AND PERSON: Oriented
 MINI MENTAL STATE EXAMINATION SCORE: 28 which denotes that patient has no cognitive
impairments.
 SPEECH: Normal
CRANIAL NERVE EXAMINATION
 Olfactory : Patient has a good sensation of smell

 Optic nerve: Normal
 Ocular nerves: As the Oculomotor, trochlear and abducens nerves are responsible for
the movements of the eyeball because of the link with extraocular muscles they are
termed as ocular nerves.
TEST IS NORMAL
 Trigeminal Nerve : No abnormalities detected.
 Facial Nerve : Buccinator and orbicularis oris are mild effected.
 The vestibulocochlear nerve : No abnormalities detected.
Rinne’s test : Normal
Weber test : Normal
 Glossopharyngeal and vagus : No abnormalities detected.
 Accessory nerve : No abnormalities detected.
 Hypoglossal nerve : No abnormalities detected.
SENSORY EXAMINATION
SUPERFICIAL-
 Pain : Normal
 Touch : Normal
 Temperature : Normal
DEEP-
 Propioception : Normal
 Kinesthesia : Normal
 Vibration : Normal
SENSORY EXAMINATION
CORTICAL EXAMINATION-
 Two Point discrimination : Normal

 Tactile Localisation : Normal
 Baragnosis : Normal
 Steregnosis : Normal
 Graphisthesia : Normal
REFLEX TESTING
Side Biceps Jerk Triceps Jerk Knee Jerk Ankle Jerk Plantar
response
Right ++ ++ ++ ++ Flexion
Left +++ +++ ++ ++ Extension

MOTOR EXAMINATION
TONE
 According to Modified Ashworth Scale-
Elbow Flexion and Wrist Flexion = 1+
 According to Brunnstrom motor recovery stage-
Left Upper limb- 4
Left Lower limb- 5
Brunnstrom Stages of Motor Recovery
1. Flaccid paralysis is present. Phasic stretch reflexes are absent or hypoactive. Active
movement cannot be elicited reflexively with a facilitatory stimulus or volitionally.
2. Spasticity is present and is felt as a resistance to passive movement. No voluntary

movement is present but a facilitatory stimulus will elicit the limb synergies
reflexively. These limb synergies consist of stereotypical flexor and extensor
movements.
Contd. . .
3. Spasticity is marked. The synergistic movements can be elicited voluntarily but are
not obligatory.
4. Spasticity decreases. Synergy patterns can be reversed if movement takes place in

the weaker synergy first. Movement combining antagonistic synergies can be
performed when the prime movers are the strong components of the synergy.
Contd. . .
5. Spasticity wanes, but is evident with rapid movement and at the extremes of range.
Synergy patterns can be revised even if the movement takes place in the strongest
synergy first. Movements that utilize the weak components of both synergies acting
as prime movers can be performed.
6.Coordination and patterns of movement can be near normal. Spasticity as

demonstrated by resistance to passive movement is no longer present. Abnormal
patterns of movement with faulty timing emerge when rapid or complex actions are
requested.
Contd. . .
7. Normal. A “normal” variety of rapid, age appropriate complex movement

patterns are possible with normal timing, coordination, strength and endurance.
There is no evidence of functional impairment compared with the normal side. There is
a “normal” sensory-perceptual motor system.
VOLUNTARY CONTROL
 Grades of voluntary Control testing
0 – No Contraction
1 – Initiation of contraction or flicker of contraction
2 – Half range of motion in pattern
3 – Full range of motion in pattern
4 – initial half range in isolation and later half in pattern
5 – Full range of motion in isolation but goes in pattern on giving resistance
6 – Full range of motion isolation and can take resistance like normals
GAIT ANALYSIS
INVESTIGATIONS
 DSA (Digital Substraction Angiogram) of brain suggests that Bilateral common carotid
arteries are normal in course, caliber and in their bifurcation. Right internal carotid
artery angiogram shows diffuse decrease caliber of its entire course narrowed
ophthalmic segment and occlusion at communicating segment with no forward flow.
 ACA branches via ACA-PCA pial-pial collaterals through perisplanial and parietal
branches.
Contd….
 Reformation of right distal cortical MCA branches via superficial temporal and middle
meningeal branches at right ECA via dural pial collaterals left internal carotid artery is
normal course and caliber. Occlusive left A1 segment with reformation of left ACA
cortical branches via MCA-ACA pial –pial collaterals.
Contd….
 MRI of Brain suggests that large area of gliosis with encephalomalacia at right MCA
territory and small gliotic area at right PCA territory.
 Gross narrowing of right internal carotid artery and both middle cerebral arteries (R >
L) with few tiny immature vessels- most likely veso-occlusive disorder.
DIFFERENTIAL DIAGNOSIS
 Right Hemispheric Ischemic Stroke
 Moya Moya disease

 Moyamoya disease is a rare, progressive cerebrovascular disorder caused by blocked arteries
at the base of the brain in an area called the basal ganglia. The name “moyamoya” means “puff
of smoke” in Japanese and describes the look of the tangle of tiny vessels formed to
compensate for the blockage.
 Moyamoya disease was first described in Japan in the 1960s and it has since been found in
individuals in the other countries around the world; its incidence is higher in Asian countries
than in Europe or North America. The disease primarily affects children, but it can also occur in
adults. In children, the first symptom of Moyamoya disease is often stroke, or recurrent
transient ischemic attacks (TIA, commonly referred to as “mini-strokes”), frequently
accompanied by muscular weakness or paralysis affecting one side of the body, or seizures.
 Adults may also experience these symptoms that arise from blocked arteries, but more often
experience a hemorrhagic stroke due to bleeding into the brain from the abnormal brain
vessels. Individuals with this disorder may have disturbed consciousness, problems with
speaking and understanding speech, sensory and cognitive impairments, involuntary
movements, and vision problems.
FINAL DIAGNOSIS
 Right Hemispheric Ischemic Stroke

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CASE PRESENTAION

NOPANY INSTITUTE OF HEALTHCARE STUDIES

 PATIENT NAME : Mrs. Sampa Dey

 Patient is having difficulty in gripping and releasing object

 She is also having balance problem during walking

 HISTORY OF PRESENT ILLNESS: Right hemispheric TIA in February 2017,

 FAMILY HISTORY: No family history of stroke.

 BODY BUILT : Mesomorphic

 GAIT : Circumductory Gait

 Right Shoulder depressed. Fingers of Left

 Blood Pressure : 140/90 mm hg on 04th May 2018 at 3:05 pm

 Heart rate : 78 bpm

HIGHER MENTAL FUNCTION

 Olfactory : Patient has a good sensation of smell

 Two Point discrimination : Normal

Left +++ +++ ++ ++ Extension

2. Spasticity is present and is felt as a resistance to passive movement. No voluntary

4. Spasticity decreases. Synergy patterns can be reversed if movement takes place in

6.Coordination and patterns of movement can be near normal. Spasticity as

7. Normal. A “normal” variety of rapid, age appropriate complex movement

 Grades of voluntary Control testing

 Right Hemispheric Ischemic Stroke

 Moya Moya disease

 Right Hemispheric Ischemic Stroke

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