1701006094 CASE PRESENTATION

 LONG  CASE  

A 70-year-old male has presented to the hospital on 06 June 2022 with the chief complaints of weakness of right upper and lower limbs,slurring of speech,difficulty in walking since 9 days

Timeline of events:

History of presenting illness:

He would wake up every day at about 6am, fresh 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.

1st episode: Patient had been asymptomatic until 3 years ago when he suddenly developed weakness in his right upper and lower limbs, with no slurring of speech. He recovered completely after the treatment 

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 dribbling of saliva. He was treated for it and recovered completely 

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. He then went to an RMP and it was found that his blood pressure was high and advised the patient to go to the hospital. It was sudden in onset and gradually progressive 

History of past illness 

diagnosed with hypertension 10 months ago and has been using atenolol 25mg since.

not a known case of diabetes, asthma, epilepsy, or TB

Personal history 

married

normal appetite

takes vegetarian diet predominantly

bowel movements: regular

micturition is normal

no known allergies

addictions: alcohol abstinence since 5 years.

No similar complaints in the family.

General Physical Examination 

Done after taking informed consent 

Done in a well-lit room, in the presence of an attendant, with adequate exposure. The patient is conscious, incoherent, cooperative, well-nourished, and well-oriented to time, but not oriented to place and person.

No pallor icterus, Cyanosis, Koilonychia, Generalised Lymphadenopathy, Pedal oedema and clubbing

Slight muscle wasting in the right upper arm 

Vitals

Temperature - afebrile

Pulse rate- 70 bpm

BP- 140/80 mm Hg

Respiratory rate- 16/min

SYSTEMIC EXAMINATION:

1. CVS: S1 & S2 heard. No murmurs

2. Respiratory system

Bilateral air entry present

Normal vesicular breath sounds heard

3. Abdomen: Soft and non-tender. No organomegaly

4. CNS:

Dominance - Right-handed

4a) Higher mental functions

conscious and cooperative but incoherent

oriented to time, but not oriented to place and person.

memory- not able to recognize family members

Speech - only comprehension, no fluency, no repetition

4b)  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

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  

   4d) Motor system examination

      4di) 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

                  

      4dii) TONE:            U/L                    increased                       normal

                                      L/L                    increased                       normal

                                                      

                          

UPPER LIMBS

LOWER LIMBS

                                                                 Right                               Left  

      4diii) 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

LOWER LIMBS

UPPER LIMBS

                                                                Right                                  Left        

       4div) REFLEXES:    Biceps            +++                                    ++

                                         Triceps            +++                                   ++

                                         Supinator        +++                                   ++

                                         Knee               +++                                   ++

                                        Ankle              +++                                    ++

                                        Plantar          extension                          neutral

RIGHT BICEP

RIGHT KNEE 

BABINSKI

      4dv) COORDINATION:  Absent 

      4dvi) GAIT

No cerebellar signs 

No meningeal signs

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

DRUGS: 

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

Physiot

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SHORT  CASE 

51 year old male patient who is resident of Suryapet ,and works in transportation company came to the OPD with cheif complains of Fever since 10 days

Cough since 10 days 

Shortness of breath since 6 days 

History of presenting illness 

The patient was apparently asymptomatic  10 days back then he developed Fever which is of high grade,intermittent ,associated with chills and rigors,relieving with medication.

Cough since 10 days which is productive,mucoid in consistency,whitish,scanty amount ,more during night times and on supine position ,non foul smelling ,non bloodstained .

Right sided chest pain - diffuse , intermittent dragging type , aggravated on cough ,non radiating not associated with sweating , palpitations.

Shortness of breath since 6 days, insidious onset , gradually progresive of grade 3 (MMRC scale ),not associated with wheeze , orthopnea , Paroxysmal nocturnal dyspnea, pedal edema .

No history of weight loss , loss of appetite,

pain abdomen , vomitings ,loose stools,

burning micturition.

History of past illness 

Patient gives history jaundice 15 days back that resolved in a week .

No history of Diabetes , Hypertension , Tuberculosis, Bronchial asthma ,COPD , coronary artery disease , Cerebrovascular accident ,thyroid disease.

Personal history 

Appetite- normal

Diet- mixed

Sleep- adequate

No bowel and bladder disturbances

Patient is a chronic smoker - smokes 5 cigarettes per day from past 25 years .

He is a chronic alcoholic - consumes 300 ml whisky per day ,but stopped since 3 months.

Family history 

Non contributory 

General physical examination 

Patient is moderately built and nourished.

He is conscious, cooperative,cohorent

No signs of pallor ,cyanosis ,icterus ,koilonychia, lymphadenopathy ,edema .

Vitals : 

Patient is afebrile .

Pulse - 86 beats / min ,normal volume ,regular rhythm,normal character ,no radio femoral delay,radio radial delay.

BP - 110/70 mmhg ,measured in supine position in both arms .

Respiratory rate -22 bpm

Systemic examination:

RESPIRATORY SYSTEM:

Inspection:-

                                                    

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear to be decreased on right side

Abdomino thoracic type of respiration

Trachea is central in position

No dilated veins, scars, sinuses, visible pulsations. 

Palpation:

All inspiratory findings are confirmed by palpation.

Vocal fremitus- decreased on right side in mammary,infra scapular,inter scapular

                         

Measurements:

Chest circumference 95cm on expiration, 98cm on inspiration

Hemi thorax: Right- 48cm; left- 46cm

Anteroposterior diameter- 26cm

Transverse diameter- 32cm 

Ratio: AP/T- 0.8

Chest expansion: 3cm

Percussion:                 Right                   Left

Supra clavicular:        resonant            resonant    

Infra clavicular:          resonant            resonant  

Mammary:                  dull                   resonant

Axillary:                     dull                   resonant  

Infra axillary:             dull                   resonant

Supra scapular:          resonant            resonant

Infra scapular:           dull                    resonant  

Inter scapular:           dull                    resonant      

Auscultation:              Right.                   Left

Supra clavicular:.       NVBS                NVBS

Infra clavicular:          NVBS                NVBS

Mammary:                  decreased           NVBS 

Axillary:                     decreased           NVBS

Infra axillary:             decreased           NVBS

Supra scapular:          NVBS                NVBS

Infra scapular:           decreased            NVBS

Inter scapular:           decreased            NVBS

PER ABDOMEN:

Inspection - 

Abdomen is distended.

Umbilicus is central in position.

All quadrants of abdomen are equally moving with respiration except Right upper quadrant .

No visible sinuses scars, visible pulsation engorged veins are seen

Palpation: 

All inspectory findings are confirmed.

No tenderness .

Liver is palpable 4 cm below the costal margin and moving with respiration.

Spleen is not palpable.

Percussion:

Resonant

Auscultation:

bowel sounds heard .

CARDIOVASCULAR SYSTEM

Inspection:

Shape of chest normal

JVP- not raised

No precordial buldge, pulsations are seen

Palpation:

Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

No murmurs

CENTRAL NERVOUS SYSTEM:

All higher mental functions, motor system, sensory system and cranial nerves- intact

PROVISIONAL DIAGNOSES:

Right sided Pleural effusion likely infectious etiology. 

Hepatomegaly - ? Hepatitis or ? Chronic liver disease 

Investigations 

PLEURAL FLUID

PLEURAL FLUID ANALYSIS 

Colour - straw coloured 

Total count -2250 cells

Differential count -60% Lymphocyte ,40% Neutrophils 

No malignant cells.

Pleural fluid sugar = 128 mg/dl

Pleural fluid protein / serum protein= 5.1/7 = 0.7 

Pleural fluid LDH / serum LDH = 190/240= 0.6

Interpretation: Exudative pleural effusion.

Other investigations:

Hemoglobin- 9.5

Total leukocyte count- 20000

neutrophils- 82

lymphocyte- 07

eosinophils- 02

basophils- 00

monocytes- 08

Platelets- 4.5 lakh

Normocytic normochromic anemia

Serology negative 

Serum creatinine-0.8 mg/dl 

Liver function tests

Total bilirubin- 0.73

Direct bilirubin- 0.20

SGOT- 15

SGPT- 11

Alkaline phosphate-197

Albumin-2.7

CUE - normal

CHEST X-ray

CT Abdomen

TREATMENT:

Inj. PIPTAZ 2.5gm iv QID

Tab. AZITHRO 500 OD

Inj. METROGYL 100mlTID

Tab. DOLO 650mg

Inj. NEOMOL 1gm iv

O2 inhalation

Ivf normal saline

Inj opifeneuron

Temperature chart 4 hrly

Bp,spo2 chart 4hrly

Inj. Amikacin iv BD