Hemiplegia

Hemiplegia

4 Personal history

A known diabetic and hypertensive patient, محمود حسين ياسين male patient, 45 years old, driver, from Cairo, has 3 off spring, the youngest is ten years old, heavy smoker, Rt. handed.

4 c/o

Heaviness on Rt. upper and lower limbs of 2 years duration.

4 HPI

The condition started 2 years ago and reached its complete picture within hours. This onset was not   associated with fever, trauma, vomiting, coma or convulsion. the patient at first developed complete paralysis associated with flaccidity, tingling and numbness in the Rt. upper and lower limbs and also had a speech defect.

        6 weeks later ,the patient experienced  weakness of gradual onset associated with  stiffness with no wasting or twitches. This weakness affected the Rt. upper and lower limbs affecting  distal more than proximal muscles, abductor more than adductor muscles, extensor more than flexors muscles in Rt. upper limb and flexor more than extensor muscles in Rt. lower limb. No involuntary movements. The condition was associated with loss of sensation in Rt. Upper and lower limbs and  the patient felt as if his Rt. leg walks on cotton and there is marked improvement in speech.

Apart from accumulation of food behind Rt. cheek, drippling of saliva from Rt. side of mouth, deviation of mouth to lt. side , deviation of tongue to the Rt. Side and dropping of the rt. Shoulder, There are no symptoms suggesting other cranial nerve affection.

No symptoms of sphincteric affection.

No symptoms of increased I.C.T.

No symptoms of cardio vascular system affection.

No other system affection.

4 Past history

-    Diabetes started 8 years ago and manifested by polyphagia, polyurea, polydypsia and treated by dimicron.

-    HPN started 6 years ago and manifested by headache blurred vision and treated by capozid.

-    No past history of fever, operation, other drug intake.

4 Family history

-          No similar condition in family.

-          No consanguinity.

-         No common disease in family.

4 General exam

-          Temperature: 37^o c.

-          Bl. Pressure: 130/70(may be higher).

-          Pulse: regular, 80 beat/minute, average volume, no special character, vessel wall not felt, equal in both sides with intact  peripheral pulsation.

-          Mentality: The patient is fully conscious, well oriented for time, place and person. Average mood and memory. The patient is co-operative with average intelligence.

4 Cranial Nerves

v      Facial nerve by inspection, there is obliterated rt. nasolabial fold but symmetrical forehead, no tears, no drippling of saliva, no deviation of the mouth. By exam of power, there is deviation of angle of mouth to left side, The patient can not blow his right cheek and can't whistle but can close his eyes firmly with normal elevation of both eye brows and symmetrical forehead wrinkles on both sides..

v      Hypoglossal nerve: the tongue is deviated to the Rt. side, decrease power on Rt. side but no fasciculation or wasting.

v      Cranial root of accessory: there is affection of trapezius of Rt. side.

v      Trigeminal N: loss of sensation on Rt. side of face.

v      Other cranial nerves were examined but no abnormality detected.

4 Examination of Motor System :

4 Inspection__

-    There is  flexion of Rt. upper limb at elbow, extension in Rt. lower limb at knee.

-    No skeletal abnormalities, no trophic changes, no involuntary movement no muscle washing.

4 Palpation__

There is normal tone in lt upper and lower limbs, in Rt. Upper and lower limbs there is hypertonia in the from of  spasticity affecting  antigravity muscle indicating UMNL in the rt upper and lower limbs.

 4 Percussion__

No fasciculation or myotonia.

4 Examination of Muscle Power

There is normal muscle power in lt upper and lower limbs. in Rt. limbs: there is  weakness affecting distal more than proximal, abductors more than adductors, in the rt. Upper limb extensors are weaker while in the rt. Lower limb flexors are more weaker Indicating weakness of D tract distribution in the rt. Upper and lower limbs.

N.B: power of abdominal muscles showed no abnormality.

4 Coordination

Cannot be examined on Rt. side because of weakness on it side there is normal coordination  proved by finger to nose ,finger to finger ,finger to doctor's finger in  both eye opening and eye closure.

4 Reflexes

-          There is normoreflexra in it upper, lower limbs.

-          In Rt. upper limb: hyperreflexia with +ve pathological reflexes.

-          In Rt. lower limb: hyperreflexia with +ve pathological reflexes and +ve clonus.

-          +ve babniski on Rt. side and normal planter response on  the left side.

-          Abdmominal reflexes lost on the right side .

4 Sensory: complete hemi-hypothesia on Rt. side.

4 Back: no deformities, no pigmentation.

4 Gait: circumduction gait.

4 No affection in other system examination.

4 Investigation

-          CT, MRI, carotid mRA, cardiac .

4 Treatment

Physiotherapy, Vitamins, Antiplatelet drugs(thrombosis), anticoagulant (embolic).

                       

4 Diagnosis :

Organic Rt. sided hemiplegia. It is thrombotic at capsular level.

The patient is in the  spastic stage.

4 Hemiplegia (Unilateral UMNL)

1. Tone antigravity + spasticity.
2. Power distor, progravity, abd.
3. Hyper reflexia + pathological reflexes + clonus.
4. +Ve babniski.
5. Hypoglossal (no fasciculation, wasting),and UMNL facial n. palsy.
6. Complete hemi hypothesia.

4 Capsular:

v      Motor: complete hemiplegia.

v      Sensory: complete hemi hypothesia.

v      Not cortical: no convulsion, coma, aphasia. Usually (monoplegia)

v      Not- spinal: cranial N affection excludes spinal.

v      Not brain stem: not crossed hemiplegia.

Embolic Hemiplegia

Differs from thrombotic hemiplegia in the following :

4 History

-          The patient is younger at time of stroke.

-          The condition reached its complete picture within seconds.

-          Start with the condition started …. Years ago by gradual onset, progressive course of  exertional dyspnea. At first, it was on climbing the 2^nd floor then it became progressively increased till became at rest and the patient had orthopnea he used to sleep on 3 pillows and he had paroxysmal nocturnal dyspnea he waked up after 2 hours of sleep with dyspnea, cough and wheeze .after 15 minutes, relief  usually occurred. This dyspnea was associated with rapid irregular palpitation increased with exertion ….. then after ….years the patient developed …………..like thrombotic.

-          Past history of rheumatic fever.

4 Examination

-          Pulse may be irregular

-          Blood pressure is usually normal

-          Cardiac exam may reveal signs of M.S (may be with AF).