1701006007 CASE PRESENTATION

 LONG CASE

A 53 year old female came with 

 altered sensorium ,difficulty in walking ,loss of speech ,weakness of right upper limb and right lower limb.

HOPI :

Patient was A known Case of Diabetes Since 11 Years and Hypertensive since 1 Year.

  She developed Giddiness which later Resolved on the Next Day.

RMP was called on and He prescribed Cinarizine and He also found that her BP was around 280 mmHg and gave Anti Hypertensive Drug(Telmisartan).

 On the next Day While she was going to washroom was unable to lift her leg and she was dragging her leg which was noticed by daughters so was brought to our Hospital .On her Way to Hospital She Couldn’t recognise her Daughters.

On Examination She Had Altered Sensorium ,Difficulty in Speaking,Weakness in Upper Limb And Lower Limb.

Daily Routine : She used To wake up At

 5: 30 am and would complete her Daily House Old Activities.

Negative History : No History of Headache,Fever,Vomiting ,Chest Pain,Palpitations and Shortness of Breadth.

Treatment History : For Diabetes - Dapaglifozin 10mg                              Metformin 500mg

For Hypertension :

Telma 40mg 

  Cilindipine 10mg 

Metoprolol 50mg

Personal History: 

Diet Mixed 

Appetite Normal,

  Bowel And Bladder Regular.

   Sleep Adequate 

No Allergies And Addictions.

Family History not Significant 

General Examination: 

Patient is Conscious, but not Cooperative and is oriented to Place and Person.

Moderately Built and Nourished.

Pallor :Absent

Icterus: Absent

Clubbing: Absent

Cyanosis :Absent

Lymphadenopathy :Absent

Edema:Absent

Vitals : 

Temperature - 100.8

Pulse 90 bpm

B.P 180/80mmHg

SpO2 94%.

SYSTEMIC EXAMINATION : 

CVS : S1 S2 heard, no murmurs

RS : Bilateral air entry present, normal vesicular breath sounds, no added sounds

GIT : Soft, non-tender, no organomegaly

CNS :

Dominance - Right handed

Higher mental functions

   

  • conscious

    • oriented to person and place

    • memory - able to recognize their family members

    • Speech - Broca's aphasia ( only comprehension, no fluency, no repitition) 

Cranial nerve examination 

   • 1 - couldn't be elicited

    • 2- Direct and indirect light reflex present

    • 3,4,6 - no ptosis Or nystagmus

    • 5- corneal reflex present  

    • 7- no deviation of mouth, forehead wrinkling present

   • 8- able to hear

   • 9,10- position of uvula couldn't be visualized

   • 11- sternocleidomastoid contraction present

     • 12- no tongue deviation

Motor system 

 Attitude - right lower limb externally rotated

Tone - Hypotonia on right side(both UL,LL)

            Normal tone on left side(UL,LL)

Bulk - Rt.                      Lt. 

 Arm 26cm.                26cm

Forearm 19cm          19cm

Thigh 42 cm.            42cm

Leg 28cm.                 28cm

Triceps reflex

Ankle jerk reflex(left)

Biceps Reflex(Right) 

Triceps reflex

    Knee Reflex(left)

Assessment of tone 

Left lower limb

Upper limb tone

Ankle jerk reflex

Babinskis positive (rt side)

Babinski (left side)

POWER :

Sensory system : responding to pain

Cerebellar signs : couldn't be elicited

Diagnostic tests:

MRI

T2  weighted image

FLAIR

ADC

DWI

 

ECG

X RAY

TEMPERATURE

Medication

TREATMENT:

IV FLUIDS-NS @ 75 ml / hr

-RT. 100ml MILK WITH PROTEIN POWDER 8th hrly

 100ml water Every 2nd hrly

-ING.CITICHOLINE800mg /IV/IN 100 ml NS/BD

-ING.PAN40mg/PO/OD

-TAB. ECOSPIRIN 150mg /PO/HS

-TAB.ATORVAS40mg/PO/OD

-TAB.AMLONG 5mg /PO/OD

-ING .HUMAN ACTRAPID INSULIN ACC. TO GRBS CHECK

-TAB . DOLO 650mg SOS if temp>100F

-B.P. MONITORING 4th hrly 

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SHORT CASE 

A 46 year old male came to casuality with c/c of   burning micturation since 10 days, vomiting since 3 days, giddines since 1 day

History of presenting illness:

Patient was apparently asymptomatic 10 yrs back, after which he complained of polyuria and diagnosed with DM type 2 and was started on OHAs, 3 years back he started taking insulin. 

20 days back he developed vomiting(3/4 episodes, non billious, non foul smelling) 

Later he complained of giddiness and brought to hospital. His GRBS was raised 

No history of fever/cough/cold 

No significant history of UTIs

Past history:

H/o DM  since 10 years. 

H/o cataract surgery 3 years back. 

1year back he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.

Not a k/c/o HTN , Epilepsy,TB, Thyroid

Not on any medication

No history of blood transfusion 

Personal history:

Diet - Mixed

Appetite- normal

Sleep- Adequate 

Bowel and bladder- Regular

Micturition- burning micturition present

Habits/Addiction:

Alcohol- stopped since 1 year

Family history:

Not significant

Vitals on Admission:

BP: 110/80 mmHg

HR: 98 bpm

RR: 18 cpm

TEMP: 101F

SpO2: 98% on RA

GRBS: 124 mg/dL

General Examination:

Pallor present 

No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy

No signs of dehydration

Systemic Examination:

CVS: S1S2 heard, No murmurs

RS: BAE+,NVBS

P/A: Soft, Non tender

CNS: 

Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal

Power: Normal(5/5) in both Upper and Lower limbs

Tone: Normal in both Upper and Lower limbs

No meningeal signs

Investigations:

On admission (19.5.22)

20.05.22

LDH- 192

24hr Urinary protein- 434

24hrs Urinary creatinine- 0.5

 

Culture report: Klebsiella Pneumonia positive

21.5.22

Hemoglobin- 6.8g%

TLC- 22,500cells/cumm

Platelets- 1.4lakhs/cu.mm

Urea- 155mg/dl

Creatinine- 4.7

Uric acid- 7.1

Phosphorus- 2.0

Sodium- 126

Potassium- 2.6

Chloride- 87

22.5.22

Hemoglobin- 7.2

TLC- 17,409

Platelet count- 1.5

Urea- 162

Uric acid- 5.0

Sodium- 125

Chloride- 88

23.2.22

25.5.22

27.5.22

Hb- 7

TLC- 22,000

Platelet count- 26,000

Urea- 144

Creatinine - 4.8

Uric acid-9.1

Phosphorus- 4.8

Sodium- 135

Potassium- 4.3

Chloride- 98

Fasting blood sugar- 149

29.5.22

Hb- 6.4

TLC- 14,700

Platelet count- 6000

Urea - 149

Creatinine- 4.4

Uric acid- 9.2

Provisional Diagnosis: 

Right emphysematous pyelonephiritis and left acute pyelonephiritis and encephalopathy (secondary to sepsis) 

H/o of Type 2 Diabetes mellitus since 10years

Treatment:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. PAN 40mg IV OD

IV Fluids- NS,RL @ 100 mL/hr

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 12:

SDP Transfusion done for low platelet count 

Pre transfusion counts:

Hb:6.2 g/dL

TLC:14700

Platelets :6000

Post transfusion counts:

Hb:6.4

Platelets:50000