1701006024 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 right 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 , seizures,

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.

Attained Menopause at -48 yrs

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 - 100.8F⁰

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 ( slightly delayed on right side, normal on left side) 

    • 7- no deviation of mouth, no loss of nasolabial folds, 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 

Power

        Right.             Left                 

UL    0/5               4/5

LL.    0/5               4/5

Reflexes        Right       Left 

                

Biceps          1+                2+

Triceps         1+                2+

Knee jerk      0                  2+

Ankle jerk    0                  1+

Supinator    2+                2+

Babinski      Extensor    Flexion

Corneal reflex present on both sides

Light reflex present on both sides

(Direct and indirect)

Biceps Reflex(Right)

Biceps reflex (left)

Tricepsreflex(left)

Triceps reflex (right)

Knee jerk reflex(right)

    Knee Reflex(left)

Assessment of tone

Left lower limb

Upper limb tone

Ankle jerk reflex (left)

Ankle jerk reflex(right)

Right supinator

Babinskis positive (rt side)

Babinski (left side)

Sensory system : responding to pain

Cerebellar signs : couldn't be elicited

Diagnostic tests:

MRI

T2  weighted image

FLAIR

ADC

DWI

COLOUR DOPPLER

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.PIRACETAM 800mgIV/IN 100ml NS/TID

-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   

Diagnosis-Acute ischemic stroke with right  hemiplegia                                          

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SHORT  CASE 

A 56 year old male patient, daily wage worker by occupation, resident of Nalgonda came to opd on 28-05-22 with

CHIEF COMPLAINTS :

1. Pain abdomen since 20 days.

2. Multiple abdominal swellings since 7 days.

3. Fever since 7 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 5 months back, then he developed cough which was insidious in onset, gradually progressive and there was no sputum. Later, he developed fever which was high grade, associated with chills and rigors. He went to the hospital with above complaints and medications were prescribed and the symptoms subsided.

After 2 months, patient observed loss of appetite and loss of weight for which he went to the doctor. Upon, his advice, the patient got tested for Tuberculosis and HIV. He tested positive for both TB and HIV. The patient was given ART and ATT.

20 days back, patient started experiencing pain around the umbilicus which was insidious in onset, gradually progressive associated with abdominal discomfort. He complains of small multiple round swellings in the abdomen since 7 days which have gradually increased to present size. He had fever since 7 days which was high grade associated with chills and rigors.

PAST HISTORY :

Patient is a known case of Tuberculosis and HIV-AIDS and is on regular treatment.

Patient is not a known case of Diabetes mellitus, Hypertension, Asthma, Epilepsy, Thyroid disorders.

There is no surgical history, no history of blood transfusions.

PERSONAL HISTORY :

Diet : Mixed

Appetite : Decreased 

Sleep : Adequate 

Bowel and Bladder movements : Regular

Addictions : None

FAMILY HISTORY :

No history of similar complaints in the family.

HISTORY OF ALLERGIES :

No known drug or food allergies.

GENERAL PHYSICAL EXAMINATION :

Patient is conscious, coherent, co-operative and well oriented to time, place and person.

Moderately built and moderately nourished.

No pallor, icterus, cyanosis, clubbing, edema

Lymphadenopathy is present. There are multiple enlarged lymph nodes in abdomen and neck. 

Cervical lymph nodes : Palpable on both sides of neck which are about 2x2 cm in size and soft to firm in consistency. 

palpation of cervical lymph nodes

Inguinal lymph nodes : Multiple palpable lymph nodes on both sides of size about 1x1 cm which are soft to firm in consistency are palpable.

Axillary and supraclavicular lymph nodes are not palpable.

Vitals :

Temperature : Febrile

Pulse Rate : 86 bpm

Blood Pressure : 120/80 mm Hg

Respiratory rate : 16 cpm

GRBS : 106 mg/dl

SYSTEMIC EXAMINATION :

Cardiovascular System : S1, S2 heard. No murmurs.

Respiratory System : Normal Vesicular Breath Sounds heard.

Central Nervous System : Conscious, Alert, Speech normal, Motor and Sensory examination normal.

Per Abdomen : Soft. No hepatomegaly. No splenomegaly. 

INVESTIGATIONS :

1. Hemogram

Hemoglobin : 7.3 g/dl

TLC : 4000 cells/mm3

Neutrophils : 78%

Lymphocytes : 13%

Eosinophils : 2%

Basophils : 0%

PCV : 20.7 vol%

MCV : 85.2 fl

MCH : 30 pg

MCHC : 35.3%

RDW-CV : 17.2%

RDW-SD : 53.7 fl

RBC count : 2.43 million/mm3

Platelet count : 2.61 lakhs/mm3

Smear : Normocytic Normochromic anemia

2. Blood sugar : 

97 mg/dl

3. ESR : 45 mm/1st hour

4. CRP : Positive (2.4 mg/dl)

5. LDH : 261 IU/L

6. HIV : Reactive

7. LFT :

Total Bilirubin : 1.22 mg/dl

Direct Bilirubin : 0.24 mg/dl

AST : 43 IU/L

ALT : 22IU/L

ALP: 375IU/L

Total protein : 6.4 g/dl

Albumin : 3g/dl

A/G : 0.88

8. RFT :

Urea : 20 mg/dl

Creatinine : 0.8 mg/dl

Uric acid : 4.0 mg/dl

Calcium : 9.3 mg/dl

Phosphorus : 3.3 mg/dl

Sodium : 139 mEq/L

Potassium : 4.1 mEq/L

Chloride : 102 mEq/L

9. CUE

10. ECG

11. Chest x-ray

12. 2D Echo

PROVISIONAL DIAGNOSIS :

Fever with generalized lymphadenopathy secondary to HIV/TB

TREATMENT :

1. Tab. Dolo 650 PO TID

2. Tab. MVT OD

3. Inj. Neomol 1g IV/SOS

4. Tab. Dolutegravir, Lamivudine, Tenofovir Disoproxil Funerate (50 mg,300 mg,300 mg) PO OD

5. Tab. Rifampicin, Isoniazid, Pyrazinamide, Ethambutol (150 mg,75 mg,400 mg,275 mg) PO OD

6. Tab. Septran-DS PO BD

7. Tab. Pan 40 mg PO BD

8. Syrup Aristozyme PO 10 ml TID