1701006072 CASE PRESENTATION

 LONG CASE:

A 70-year-old male has presented to the hospital on 06 June 2022 with the chief complaints of

• slurring of speech And difficulty in walking
• weakness of right upper and lower limbs 

It is from 9 days 

Time line of events are :

 HISTORY OF PRESENT ILLNESS:

. He wake up every day at about 6am, freshen up, have breakfast and do his daily activities like grazing the cattle till the afternoon. He would then have lunch and take a nap till evening. He  spend time  with the neighbours for rest of the day.

Patient was apparently asymptomatic 3 yrs ago then he developed weakness of RT upper limb and lower limb  which is sudden in onset  which was treated and he recovered 

2nd episode  of RT upper limb and lower limb weakness and dropping of mouth , drooling of saliva developed 1 year back. It was treated and he recovered

3rd episode: He developed weakness of the right upper and lower limbs 9 days ago. He first was not able to walk then eat and then developed speech abnormality.    Local doctor advised the patient to go to the hospital due to high blood pressure and symptoms are  sudden in onset and progressed gradually.

Past history

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

Personal history 

      

  DIET- mixed

Appetite: Normal

Bowel and bladder movements are regular

Sleep: Adequate

No known addictions and allergies.

General examination

General examination conscious , incoherent, cooperative

No pallor

      Icterus

      Cyanosis

       Clubing

       Lymphadenopathy

Vitals

         BP 120/70mmhg

         PR 79 BPM

         RR 20

         Spo2 95 

Systemic examination

       Respiratory examination

        BAE +ve and normal vesicular breath sound                 heard 

        No crepts heard 

      CVS examination

       S1S2 heard 

        No murmurs heard

        Abdomen examination

        Soft non tender

        No hepatomegaly and splenomegaly

CNS:

   Higher mental functions   

conscious and cooperative but incoherent

oriented to time, 

memory- not able to recognize family members but now able to recognise 

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

  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-  normal eye movement  no diplopia 

V- Trigeminal nerve- sensory and motor function are intact

VII- Facial nerve- face is symmetrical,   left nasolabial fold prominent than right. And drooling of saliva from RT side and unable to clench his teeth

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

 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 

Motor system examination

    

                                        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

                  

                                                     Right     Left

TONE:                           U/L decreased   normal

                                      L/L decreased   normal

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

                                            - elbow 2/5       4/5

                                            - shoulder 0/5   5/5

                                      L/L- hip 0/5               4/5

                                           - knee 0/5              5/5   

                                           - ankle 0/5             4/5            

Reflexes.                                    Right.        Left

                                   

                                    Biceps.   +++.             ++

                                   Triceps.    +++.            ++

                                   Supinator.  +++.           ++

                                   Knee.         +++.             ++

                                   Ankle.        +++.            ++

COORDINATION: Absent 

GAIT hemiplegic gait

https://photos.app.goo.gl/To4i5zS2EKBYZYeUAexamination

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)

MRI

ECG

Carotid artery Doppler

  

Bilateral internal carotid artery stenosis Lt>Rt

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:

A 47 year old female tailor by occupation resident of nalgonda came to the OPD on 2_06_2022 with the chief complaints of 

Fever since 3 months

Facial rash from  15 days

History of presenting illness: 

Patient apparently asymptomatic 10 years back later she developed joint pains (in ankle and knee) it was associated with morning stiffness and limitation of joint movement . This get usually relieved after some activity .

For joint pains she went to local hospital where she tested RA positive

She was on diclofenac for 2 months and symptoms relieved

Last year she took COVID vaccination

Later she developed joint pains

After which she consulted orthopaedician  and symptoms relieved by taking medication

3months back  she  had joint pains and  fever which was Insidious in onset Intermittent on and off not associated with chills and rigor. 

She went to the private hospital but the fever was recurrent associated with abdominal pain came here on 2/6/22

Patient also had facial rash over the face which increased on exposure to sun. It was a diffuse erythematous lesion and hyperpigmented papules were noted over the bilateral cheek sparing nasolabial folds and it developed from last 15 days

Past history

Patient had an history of gradual painless loss of vision since 2011and was certified as blind  2 years back

Not a known case of diabetes asthma Epilepsy thyroid tuberculosis and coronary artery disease. 

No similar complaints in the family

Personal history

DIET- mixed

Appetite: Normal

Bowel and bladder movements are regular

Sleep: Adequate

No known addictions and allergies.

General examination

Pateint is consious coherent co operative well oriented to time place and person,moderately built and moderately nourished and is examined with informed consent.

Pallor: present 

No icterus, cyanosis, clubbing,lymphadenopathy, edema.

VITALS

PULSE :86BPM

BP:120/80mm hg

RR:16cpm

SPO2:98%at room air

Local examination

Erythematous rashes seen bilaterally around cheeks

And it is insidious onset  and gradually subsided

 

A swelling seen on lateral aspect of left leg just above the ankle joint associated with itching , theombong type of pain and redness

Later pigmentation seen .

SYSTEMIC EXAMINATION 

CVS

Inspection:

SHAPE OF THE CHEST IS NORMAL

No visible neck veins

No rise in JVP

No visible pulsation scars.

Palpation

ALL inspectory findings are confirmed 

Cardiac impulse felt at 5ty intercostal space 1cm medial to the mid clavicular line.

Percussion shows normal heart borders

Auscultation: s1 s2 heard no  murmurs

CNS 

Higher mental function normal 

Cranial nerve examination normal 

Normal motar and sensory system on examination

Respiratory examination

Inspection

Shape of chest is elliptical, 

B/L symmetrical chest,

Trachea in central position,

Expansion of chest- normal on both sides

Palpation

All inspectory findings are confirmed,

No tenderness, No local rise of temperature,

Percussion

normal resonant note present bilaterally 

auscultation: normal vesicular breath sounds heard 

GIT 

inspection- normal scaphoid abdomen with no pulsations and scars

palpation - inspectory findings are confirmed

no organomegaly, non tender and soft 

percussion- normal resonant note present, liver border normal

auscultation-normal abdominal sounds heard, no bruit present 

INVESTIGATIONS:

CBP

• Hemoglobin- 6 gm/dl 
• PCV- 21 % 
• TLC- 8200/ cumm 
• RBC- 2.5 million/cumm 
• Platelets- 1.32 lakhs/ml 

RA Factor- 34.4 IU/L 

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- 48IU/L 

SGOT- 55IU/L 

ALP- 194 IU/L 

Albumin- 4 g/dl (N)

INVESTIGATIONS:

CBP

• Hemoglobin- 6 gm/dl 
• PCV- 21 % 
• TLC- 8200/ cumm 
• RBC- 2.5 million/cumm 
• Platelets- 1.32 lakhs/ml 

RA Factor- 34.4 IU/L 

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- 48IU/L 

SGOT- 55IU/L 

ALP- 194 IU/L 

Albumin- 4 g/dl (N)

XRAY

Chest x ray pA view

Ophthalmology report 

Bilateral optic atrophy 

Treatment given 

PROVISIONAL DIAGNOSIS:

SECONDARY SJOGRENS SYNDROME 

LEFT LOWER LIMB CELLULITIS WITH BILATERAL OPTIC ATROPHY.