1701006054 CASE PRESENTATION

LONG CASE

A 70 year old male complaints of weakness in his right upper and lower limbs admitted on 6th June

Chief complaints

Patient complaints of ;

Weakness of right upper and lower limbs

Slurring of speech

History of presenting illness:

Patient was apparently asymptomatic 4 days back

Then he suddenly developed weakness in his right upper limb while eat

Then weakness in his right lower limb

Then deviation of his angle of mouth to left side

Then slurring of speech developed

Past history ;

The patient was leading a peaceful life with his wife. He would wake up every day at about 6am, freshen up, have breakfast and do his daily chores like grazing the cattle till the afternoon. He would then have lunch and take a nap till evening. He then hung out with the neighbours, had dinner and rested for the day. This was his routine for the past 8 years

1st episode: Patient had been asymptomatic until 3 years ago when he suddenly acquired weakness in his right upper and lower limbs, with no slurring of speech. After being treated, he was able to recover.

2nd episode: He suffered a second episode of abrupt onset weakening of the right upper and lower limbs a year ago, which was accompanied by drooping of the mouth and saliva dribbling. He was treated for it again and fully healed.

not a known case of diabetes, asthma, epilepsy, or TB. diagnosed with hypertension 10 months ago and has been using atenolol 25mg since.

Personal history;

Diet : stopped non-veg 5 years back

Appetite: normal

Sleep: adequate

Bowel and bladder : normal

Addictions: occasional alcohol

No allergies

Family history:

Insignificant

General examination

Patient is conscious cooperative

Well oriented to time but not place and person

Moderately built and nourished

Pallor is present

No icterus, cyanosis, clubbing, lymphadenopathy, edema

Vitals;

Temp: afebrile

BP:140/80 mm of hg

Respiratory rate:16bpm

Pulse rate: 70bpm

Spo2 :98%

Systemic examination ;

CVS: s1 s2 heard

No murmurs

Respiratory system; normal vesicular breath sounds are heard

Abdomen: soft non tender no organomegly

CNS;

Higher functions:

Right handed

Conscious

Oriented to time not place and person

Memory: recent- present

Immediate: present

Remote: absent

Speech:

Not spontaneous

comprehension- present

Naming- absent

Repition- absent

Disarticulation of speech - present

No delusions or hallucinations

Cranial nerve examination:

I- Olfactory nerve- sense of smell present

II- Optic nerve- direct and indirect light reflex present

III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis

V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.

VII- Facial nerve- face is symmetrical, unable to do forehead wrinkling, left nasolabial fold prominent than right.

VIII- Vestibulocochlear nerve- no hearing loss

IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised

XI- Accessory nerve- sternocleidomastoid contraction present

XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue

Spinomotor system:

Right Left

BULK: U/L- arm 24.5 cm 26 cm

-forearm 18 cm 18 cm

L/L- thigh 44 cm 44 cm

- leg 28 cm 28 cm

TONE: U/L decreased normal

L/L decreased normal

4c) Sensory system examination:

Right Left

crude touch present present
fine touch absent present
pain absent present
vibration absent present
temperature absent present
stereognosis- absent present
2 pt discrimination- absent present
graphaesthesia- absent present

Right Left

POWER: U/L- hand 0/5 5/5

- elbow 0/5 4/5

- shoulder 0/5 5/5

L/L- hip 0/5 4/5

- knee 0/5 5/5

- ankle 0/5 4/5

Right Left

REFLEXES: Biceps +++ ++

Triceps +++ ++

Supinator +++ ++

Knee +++ ++

Ankle +++ ++

Plantar extension neutral

COORDINATION: Absent

GAIT

INVESTIGATIONS:

CBP

Hemoglobin- 12.6 gm/dl (N)
PCV- 35.2 % (N)
TLC- 8600/ cumm (N)
RBC- 4.33 million/cumm (N)
Platelets- 2.58 lakhs/ml (N)

Blood urea- 24 mg/dl (N)

Serum creatinine- 1.3 mg/dl (N)

Serum sodium- 136 mEq/L (N)

Serum potassium- 3.7 mmol/l (N)

Serum chloride- 104 mEq/L (N)

LFT

Total bilirubin- 0.61 mg/dl (N)

Direct bilirubin- 0.16 mg/dl (N)

SGPT- 11 (N)

SGOT- 13 (N)

ALP- 105 IU/L (N)

Albumin- 4 g/dl (N)

ECG

MRI

PROVISIONAL DIAGNOSIS:

Acute ischemic stroke causing right sided hemiplegia (left MCA territory)

Recurrent CVA

TREATMENT:

Tab. Ecosporine 150mg

Tab. Clopidogrel 75 mg

Tab. Atorvas 40mg

Tab. Atenolol 25mg

Physiotherapy

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SHORT CASE

45 year old female complaints of abdominal distension and facial puffiness

Chieftain complaints

Patient complaints of

Abdominal distension since 1year

Facial puffiness since 1year

Weight gain since 1year

Itching and rash since 1year

Shortness of breath since 1week

History of presenting illness

Patient was apparently asymptomatic 1year back then she developed abdominal distension which was insidious in onset and gradually progressive

It was associated with itching and rash which started near elbow joint and gradually progressed all over the body since 1year

complaints of facial puffiness, pedal edema and SOB since 1week

Patient also had a episode of vomiting

Past history

Patient has a history of bilateral knee pain since 3 years which was insidious in onset gradual in progression pricking type of pain more in the night aggregate on walking relieves on lying down

She also has a history of itch and rash since 1 year which was diagnosed as tinea and is on medication since then

Not a known case of diabetes/ hypertension/ tuberculosis/ asthma/ epilepsy