1701006158 CASE PRESENTATION
LONG CASE:
This is a case of a 70 year old male who was cattle grazer by occupation came to the casuality with
CHIEF COMPLAINTS:
- Weakness in the right sided upper limbs and lower limbs since 3 days
- Slurring of speech since 3 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 5 years back, then he had experienced weakness in right upper and lower limbs. It was sudden in onset not associated with slurring of speech or drooling of saliva. Patient complained that he suddenly couldn't move his right upper and lower limbs while walking up the stairs. Then he was treated conservatively and weakness subsided completely.
Then he experienced a similar attack 2 years back. He complained of weakness of right upper and lower limb associated with slurring of speech and drooling of saliva. He was treated and the weakness subsided . Patient was advised not to do heavy works.
Presently he came with the similar complaint of weakness of right sided upper limb and lower limb and slurring of speech since 3 days.
He was unable to recognize his family members.
PAST HISTORY:
Known case of Hypertension since 1 year , been on regular medication since then ( Tab. Atenolol)
Not a known case of Diabetes Mellitus, tuberculosis, asthma, epilepsy
PERSONAL HISTORY:
Diet: vegetarian diet predominantly
Appetite: Normal
Sleep: Adequate
Bowel and bladder habits: Regular
Addictions: Used to consume alcohol occasionally
Stopped since 5 years
No known allergies
FAMILY HISTORY:
No H/O similar complaints in the family
GENERAL EXAMINATION:
Patient is examined in a well lit room after obtaining informed consent.
Patient is conscious, incoherent and cooperative.
Patient is moderately built and moderately nourished.
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.
VITALS:
Temperature: Afebrile
BP: 140/80 mmHg
Pulse rate: 72 bpm
Resp rate: 18 cycles/min
GRBS: 156 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1 S2 heard, no murmurs
RS: Normal vesicular breath sounds heard
Per Abdomen: soft, non-tender, no organomegaly
CNS:
HIGHER MENTAL FUNCTIONS:
Conscious,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
CRANIAL NERVES:
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
MOTOR EXAMINATION:
i) BULK: Right Left
Arm 24.5cm 26cm
Forearm 18cm 18cm
Thigh 44cm 44cm
Leg 28cm 28cm
ii) TONE: Right Left
Upper limbs Decreased Normal
Lower limbs Decreased Normal
iii) POWER: Rt Lt
U/L
Hand 0/5 4/5
Elbow 0/5 4/5
Shoulder 0/5 4/5
L/L
Hip 0/5 4/5
Knee 0/5 5/5
Ankle 0/5 4/5
iv) REFLEXES: Rt Lt
Biceps 3+ 2+
Triceps 3+ 2+
Supinator 3+ 2+
Knee 3+ 2+
Ankle - -
Plantar Extension Neutral
SENSORY EXAMINATION:
Right Left
Crude touch present absent
Fine touch absent present
Pain absent present
Vibration absent present
Temperature absent present
Stereognosis absent present
2 pt discrimination: absent present
CEREBELLAR SIGNS: Normal
GAIT: Walks with support
No signs of meningeal irritation
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)
CASE PRESENTATION:
A 45 year old male, who works in a parcel company came to the OPD with
CHIEF COMPLAINTS:
- Shortness of breath on exertion since 2 months
- Tingling and numbness of the limbs since 2 months
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 months back , then he developed shortness of breath which was insidious in onset, initially grade 2 (NYHA) then progressed to grade 3.
Patient complains of tingling and numbness of both the limbs since 2 months. Initially it was confined to lower limbs then later involved upper limbs as well.
Patient also complains of passing dark coloured stools 3 days back.
PAST HISTORY :
No similar complains in the past
Patient had an episode of involuntary tonic clonic movements with uprolling of eyes and drooling of saliva 20 years back. Then he went to the hospital and was diagnosed as epilepsy. He took medication , later after 15 days he experienced 2-3 episodes of seizures. After that he had seizure free period.
Not a known case of hypertension, diabetes mellitus, asthma, TB
PERSONAL HISTORY:
Diet: Mixed
Appetite: Decreased
Sleep: Adequate
Bowel and bladder habits: passage of dark coloured stools 3 days back , one episode per day
Addictions: Used to consume alcohol daily since 12 years about 90 ml everyday
Alcohol abstinence since 2 months
FAMILY HISTORY : Insignificant
GENERAL EXAMINATION:
Patient is examined in a well lit room after obtaining informed consent.
Patient is conscious, coherent and cooperative.
Patient is moderately built and moderately nourished.
Pallor - present
No signs of cyanosis, clubbing, lymphadenopathy and edema.
VITALS :
Temp: 98.6°F
BP: 110/80 mmHg
Resp rate: 16 cpm
Pulse rate: 80 bpm
SpO2: 98%
GRBS: 108
SYSTEMIC EXAMINATION:
CVS : S1S2 heard, no murmurs
RS: NVBS heard
Per Abdomen: soft, non tender, no organomegaly
CNS : Normal
INVESTIGATIONS:
10/6/22:
CBP:
Hb : 3.2 g/dl
TLC: 3,400 cells/cumm
Neutrophils: 42
Lymphocytes: 56
Eosinophils: 0
Monocytes: 02
Basophils: 0
PCV : 9.2
MCV: 117.9
MCH: 42
MCHC: 34.8
RDW-CV: 24.2
RBC: 0.78
Platelets: 68,000
ESR: 40
Reticulocyte count: 0.5
LFT:
TB: 2.69
DB: 0.70
ALT: 14
AST:51
ALP: 115
TP: 5.8
Albumin: 3.6
A/G: 1.69
RFT:
Blood urea: 16
Sr. Creatinine: 0.8
Sr. Uric acid: 7.8
Sr. Electrolytes:
Sr. Calcium: 8.9
Sr. Phosphorus: 3.9
Na+: 133
Cl: 107
K+: 3.8
RBS: 104
LIPID PROFILE:
Total cholesterol: 90
Triglycerides: 116
HDL: 24
LDL: 49
VLDL: 23
12/6/22:
Hb: 2.8 g%
TLC: 2380
Neutrophils : 36
Lymphocytes: 60
Eosinophils:0
Monocytes: 4
Basophils: 0
PCV: 8
MCV: 115.8
MCH: 39.8
MCHC: 34.3
RDW-CV: 33.5
RBC: 0.69
PLT: 72,000
PS: Anisopoikilocytosis with hypochromia with microcytes, macrocytes and pencil cells.
PROVISIONAL DIAGNOSIS:
Pancytopenia ? 2° to vitamin B12 deficiency
TREATMENT:
INJ. VITCOFOL 1000mcg/IM/OD × 7 days
INJ. OPTINEURON 1AMP IN 100ml
TAB. PANTOP 40mg/PO/OD
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