CASE STUDY

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CASE STUDY
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• PRELIMINARY DATA
• Name Mr St C
• Age 54 years
• Sex male
• Religion Christian
• Address Attavar, Mangalore, now in St. Antony
  for the past 2 years
• Education Diploma in Electronics
• Marital Status Bachelor

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• CHIEF COMPLIANT
• Patient presents with the complaints of weakness
  in the right upper limb lower limb for the past
  2 ½ years.

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• HISTORY Of CHIEF COMPLAINT
• Patient was apparently well before 2 ½ years.
  One-day afternoon, soon after having food while
  patient was sitting in chair and repairing TV, he
  experienced sudden weakness in the right side of
  the sole, which ascended up and affected the
  whole of the right side of the body within I
  hour. At that time, he also experienced pain,
  which was of pulling type, pulling upwards. Along
  with this, he even experienced vertigo and he
  supported the wall with the left hand. As he was
  sitting in chair, he did not fall. Patient was
  conscious at that time. His colleague workers in
  shop noticed this and admitted him to hospital
  within 1 ½ hours of the attack. He was not able
  to speak and was not able to move the right side
  of the body.

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• In hospital, he said that he had increased BP.
  Therefore, around 10 days, he was not able to do
  any sort of work, except having food he got
  physiotherapy treatment 2 times/day and with that
  he felt better within 10 days, as he was able to
  move the body parts. Along with that even, he
  used to take 2 tablets, 1 for hypertension and 1
  antiparlytic tablet 2 times / day. Now also he is
  continuing this medication within 10 days,
  patient started walking with help. He stayed in
  the hospital for 1 month and then got discharged.
  There is difficulty in doing the activities like
  eating and shaving (uses spoon barber).
  However, there is no difficulty in combing or
  wearing the shirt or wearing the slippers. He
  also complains of constipation from that time
  (once in 3 days), Now under Ayurvedic Rx for
  that. There is no history of headache, loss of
  vision fall trauma to head, memory loss, and
  fever. Patient is feeling comfortable by sitting
  than lying down.

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CHIEF COMPLAINTS
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• PAST HISTORY No H/o DM, rheumatic fever,
  epilepsy, migraine, head injury, cardiac disease
  etc
• Treatment HISTORY Allopathic treatment for
  hypertension and antiparalytic tablets
• ALLERGIC HISTORY NAD
• FAMILY HISTORY
• Father-died at the age of 48 years because of
  high BP and heart failure
• Mother died at the age of 52 years because of
  high BP

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Patient as a Person

• PERSONAL HISTORY
• Diet Mixed
• Appetite Decreased
• Thirst Good 4- 5 glasses /day cold water
• Bowel Once / 2 days
• Bladder 4 5 times / day, no difficulties
• Craving Mutton3, Chicken 3, Sweet 2
• Aversion Pork 3
• Thermal State Hot patient

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• LIFE SPACE INVESTIGATION
• Patient belongs to a middle class family. He has
  one elder brother and two sisters and one younger
  brother. His house is in attavar Mangalore. His
  father was working in Saudi Arabia in Mahindra
  Mahindra Company. Patient studied till B.Com
  after getting B.Com Degree, he went to Bombay for
  higher studies. There he got Diploma in
  Electronics. After this, he was working in
  chemical industry. During this time his mother
  was ill patient was very much attached to her he
  came back to Mangalore, soon she expired due to
  high BP.

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• He did not get married because that time any one
  did not support him. 4 girls loved him but he
  was not in a situation to love them back. Now he
  feels sad about this because now nobody is there
  to look after him.
• Patient by nature is very quite, if any one is
  scolding him or shouting at him, he will not
  react to that or shout back. He is bit sad now
  because there is no one to look after him.
  Patient likes to talk and easily becomes friendly
  with others.

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• LIFE SPACE DATA (2)
• Points that was not included in it during
  presentation
• About what happen to work area of the patient
  after he got the attack of paralysis
• When the patient got paralysis, he left the shop,
  which he own told it.
• When he was young girls proposed him, as he did
  not have anyone to support him, he did not accept
  their proposal. Now the patient feels bad for it
  feels lonely, as he does not have any one along
  with him now.

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• Examination
• General Survey
• - Moderately built and moderately nourished
• - Well orientated with time place and person
• - No signs of pallor, cyanosis, clubbing,
  icterus, Lymphadenopathy, Oedema
• - Oral hygiene Good
• Vital Signs
• Pulse 60 beats/ min, regular rhythm, moderate
  volume, vessel wall not thickened
• BP 120/70 mm of Hg, Right arm supine position
• Temperature Afebrile at the time of examination
• Respiratory Rate 16/ breaths/ min

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• Systemic examination
• Nervous System
• Higher function Patient is fully conscious and
  well oriented with time, place and person
• Memory Intact Recent Remote
• Intelligence good
• Appearance and Behaviour Normal
• Speech Spastic type of dysarthria
• No delusion, hallucination or delirium

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• Examination of Cranial nerves
• Olfactory nerve Intact
• Optic Nerve Visual acuity far vision with
  specks
• - Near vision - - Intact
• Visual field Slightly
  reduced
• Colour vision Intact
• Oculomotor, Trochlear Abducent
• - Oculomotor intact
• - Pupillary reflex Light
  reflex
• Aecomod reflex. Intact
• Trigeminal Nerve
• Motor Jaw jerk Absent
• Muscles of mastication Intact
• Sensory touch, pain, prick- intact
• Corneal reflex intact

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• Facial Nerve
• Motor Frowning
• closing eyes
• smile or show teeth Intact
• blowing
• clenching
• whistling
• Sensory Ant 2/3 rd of the tongue taste
  intact
• Vestibulo Cocclear Rombergs test
• - Rinnes Test
• - Webbers test
• Gllossopharyngeal nerve
• Taste post 1/3 of tongue intact
• Palatal reflex intact
• Vagus
• Psm of uvula central
• Spinal accessory
• Trapezeinus sternocleido mastoid slightly
  diminished in right side
• Hypoglosal

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• Examination of Sensory system
• - Tactile sensibility
• - Light touch
• - Pressure
  Intact
• - Tactile location
• - Tactile discrimination 2 points
• Pain sensibility Intact
• Thermal Sensibility Intact
• Sense of PSn
• Vibration sense
• Stereognosis Normal
• Graphesthesia
• Examination of Motor system
• - Bulk of Muscle Rt
  Lt
• Circumferences of arm 22.5
  22
• of Fore arm 18.5
  20.5
• leg 20
  26
• thigh
  32 35
• Power grade 5

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• Reflexes
• Superficial Corneal ve on both side
• Plantar ( Babinskys sign positive on right
  side
• - Deep Biceps
• Triceps
• Knee jerk exaggerated on right side
• Ankle jerk

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• Clonus Absent
• CVS S1 S2 heard
• No Murmurs
• RS NVBS heard
• No added sounds

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• 
  
  Upper motor lesion with HTN
  H/o CVA

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• PRx Silicea Dr.x Pulsatillla
• - Mild Mild
• App decreased Loneliness
• Constipation Likes company
• Aversion meat Aversion fatty food
• Paralysis Thermal state Hot

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