1701006154 CASE PRESENTATION

Long case 

This is a case of a 50 year old male with the chief complaints of - 

Weakness of right upper and lower limbs with slurring of speech and deviation of mouth since 2 days

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 30 years ago. He then sustained a fracture close to his right elbow. He currently cannot extended his elbow completely.

1 month ago he developed giddiness and weakness of left upper and lower limbs which was sudden in onset followed by fall. He was then taken to the hospital where he was treated for the same and diagnosed with hypertension. His symptoms resolved in around 3 days. The patient was complaint with his hypertension medication for 20 days and stopped taking it after that. 

The patient then developed weakness of right upper limb and lower limb which was sudden in onset. He noticed the weakness on his right side when he woke up in the morning. He felt unsteady as he stood up after waking up. 

The weakness of right side was also associated with slurring of speech and deviation of the mouth to his left side. He was taken to a hospital nearby where he underwent a CT scan. He was then referred to our hospital the next day.

There is no history of difficulty in swallowing, behavioural abnormalities, fainting, sensory disturbances, fever, neck stiffness, altered sensorium, headache, vomiting, seizures, abnormal movements, falls.

PAST HISTORY:-

He is known case of hypertension from past 1 month

No history of diabetes, asthma, TB, epilepsy, coronary artery disease, or any thyroid abnormalities.

PERSONAL HISTORY:- 

( daily routine )

The patient wakes up at 4:00am in the morning daily. He has tea and goes to work in the ice factory. He lives very close to the ice factory. He comes home and has breakfast at around 8 to 9 am. He usually has rice and curry for breakfast. He then goes back to work and comes home for lunch at around 2:00 pm. He usually has rice with curry and dal for lunch. He consumes chicken or mutton thrice weekly. He sometimes takes a nap in the afternoon depending on his work for the day. He finishes work by around 6:00 pm following which he comes home, has tea and takes a bath. Sometimes he works until 9:00 pm. He sleeps by 9:00 pm. 

The patient has been chewing tobacco for around 10 years. 1 packet of tobacco lasts for 2 days. 

He consumes alcohol on a regular basis since 30 years. He stopped for around 3 years and started again 6 months ago after the death of his daughter’s husband.

Bowel and bladder movements are regular.

TREATMENT HISTORY:- 

He consumed medication for hypertension - Amlodipine and Atenolol for 20 days which he stopped around 10 days ago.

FAMILY HISTORY:- 

No similar complaints in the family.

GENERAL EXAMINATION:- 

Patient is conscious, cooperative, with slurred speech 

Well oriented to time, place and person

Moderately built and moderately nourished.

Vitals :- 

Temp - afebrile

BP  - 140/80 mm Hg

Pulse rate - 78 bpm

Respiratory rate - 14 cycles per minute 

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - absent 

SYSTEMATIC EXAMINATION:-

1) CNS EXAMINATION :- 

No meningeal signs like neck stiffness and Kernigs sign

Glasgow scale - 15/15

Gait - walks only with support 

Cranial nerves - 

I - no alteration in smell

II - no visual disturbances

III, IV, VI - eyes move in all directions

V - sensations of face normal, can chew food normally 

VII - Deviation of mouth to the left side, upper half of right side and left side normal

VIII - hearing is normal, no vertigo or nystagmus 

IX,X - no difficulty in swallowing 

XI - neck can move in all directions 

XII - tongue movements normal, no deviation

Pupils - both are normal in size, reactive to light

 

Power:-

Rt UL - 3/5 Lt UL-5/5

Rt LL - 3/5  Lt LL-5/5

Tone:-

Rt UL - Increased

Lt UL- Normal

Rt LL- Increased

Lt LL- Normal

Reflexes: 

                   Right                    Left

Biceps.                      

                +++                    +++

Triceps.                      

                     +++                    +++

Supinator.                 

                     +++                    +++

Knee.                          

                     +++                    +++

Ankle.                          

                     +++                    +++

Plantar:                  

                      Muted             Flexion

Involuntary movements - absent

Fasciculations - absent

Sensory system - 

Pain, temperature, crude touch, pressure sensations normal

Fine touch, vibration, proprioception normal

No abnormal sensory symptoms 

Cerebellum - 

Finger nose test normal, no dysdiadochokinesia, Rhomberg test could not be done

Autonomic nervous system - normal 

2) CVS EXAMINATION :-

JVP: Not raised

INSPECTION:

Chest wall symmetrical

Pulsations not seen

 

PALPATION:

Apical impulse – normal

Pulsations – normal

Thrills absent

 

PERCUSSION:

No abnormal findings

 

AUSCULTATION: 

S1, S2 heard

No murmurs 

No added sounds

3) ABDOMINAL EXAMINATION :- 

INSPECTION:

1. Shape – flat

2. Flanks – free

3. Umbilicus – Position-central, Shape-normal

4. Skin – normal

5. Hernial Orifices - normal 

 

PALPATION:

 

Abdomen is soft and non tender

No hepatomegaly

No splenomegaly 

Kidneys not enlarged, no renal angle tenderness

No other palpable swellings

Hernial orifices normal

 

PERCUSSION:

Fluid Thrill/Shifting dullness/Puddle’s sign absent

 

AUSCULTATION:

Bowel sounds – normal 

No bruits, rub or venous hum

4) RESPIRATORY EXAMINATION :- 

- Chest bilaterally symmetrical, all quadrants

moves equally with respiration.

- Trachea central, chest expansion normal.

- Resonant on percussion

- Bilateral equal air entry, no added sounds heard.

1. Breath sounds -  Normal Vesicular Breath sounds

2. Added sounds - absent

3.  Vocal Resonance - normal

4. Bronchophony, Egophony, Whispering Pectoriloquy absent

INVESTIGATIONS 

Anti HCV antibodies rapid - non reactive 

HIV 1/2 rapid test - non reactive

Blood sugar random - 109 mg/dl 

FBS - 114 mg/dl

Hemoglobin- 13.4 gm/dl

WBC-7,800 cells/cu mm

Neutrophils- 70%

Lymphocytes- 21%

Eosinophils- 01%

Monocytes- 8%

Basophils- 0

PCV- 40 vol%

MCV- 89.9 fl 

MCH- 30.1 pg

MCHC- 33.5%

RBC count- 4.45 millions/cumm

Platelet counts- 3.01 lakhs/ cu mm

SMEAR:

RBC - normocytic normochromic

WBC - with in normal limits

Platelets - Adequate

Haemoparasites - no 

CUE:

Colour - pale yellow

Appearance- clear 

Reaction - acidic

Sp.gravity - 1.010

Albumin - trace

Sugar - nil

Bile salts - nil

Bile pigments - nil

Pus cells - 3-4 /HPF

Epithelial cells - 2-3/HPF

RBC s - nil 

Crystals - nil

Casts - nil 

Amorphous deposits - absent

LFTs:

Total bilirubin - 1.71 mg/dl

Direct bilirubin- 0.48 mg/dl

AST - 15 IU/L

ALT - 14 IU/L

Alkaline phosphatase - 149 IU/L

Total proteins - 6.3 g/dl

Albumin - 3.6 g/dl

A/G ratio - 1.36

Blood urea - 19 mg/dl

Serum creatinine - 1.1 mg/dl

Electrolytes 

Sodium - 141 mEq/L

Potassium - 3.7 mEq/L

Chloride - 104 mEq/L

Calcium ionised - 1.02 mmol/L

T3 - 0.75 ng/ml 

T4 - 8 mcg/dl 

TSH - 2.18 mIU/ml

MRI BRAIN:

ACUTE INFARCT IN POSTERIOR LIMB OF LEFT INTERNAL CAPSULE

OLD LACUNAR INFARCT IN LEFT SIDE OF PONS

FEW MICROHEMORRHAGES IN BILATERAL CEREBRAL HEMISPHERES

MR ANGIOGRAM NORMAL

CT Scan

ECG

PROVISIONAL DIAGNOSIS:- 

Cerebrovascular accident with Right Hemiparesis due to involvement of internal capsule posterior limb

TREATMENT:-

Inj. OPTINEURON in NS 100 ml

Tab. ECOSPRIN

Tab. CLOPITAB

Tab. ATOROVAS

Tab. STAMLO BETA

Physiotherapy

--------------------------------------------------------------------------------------------------

short case

A 18 year old female came to casuality on 3/1/23

With chief complaints of

Sob since 2days

feversince 1 week,,

Pain and swelling in the perianal region since 10 days

 

HOPI: The patient was apparently asymptomatic 9 years ago 

Course of events:

9 years ago:

She had polyuria,polydipsia,polyphagia weakness and weight loss due to which she visited a local hospital and there her grbs was high and  was diagnosed to be having diabetes and started on insulin  injection and was using since then?

Inj mixtard 20U - x- 15U.

In between due to raised sugar levels she develops abdominal pain and consults a doctor and takes fluids and high dose of insulin 

1 week ago: 

Patient had swelling over Analverge a which was initially 1x 1cns and progressed to the present size of 4x4 cms associated with discharge of pus and mixed with blood, associated with High grade fever associated with chills and rigor for which she consulted local doctor and prescribed antibiotics and she used for 5 days and also developed nausea due to which she was not on proper diet and so she decreased her insulin dosage to 5u - 5u  on her own since    3 days and developed sob on rest  since 2 days and yesterday as sob was increased and got her Grbs checked at home and it was 480mg/dl and was taken to local hospital and was given injection  ( not known)and since today morning her  sob was increased went to hospital and RBS being high insulin14u HAI given and referred here for further management

Past history:

H/O similar complaints of swelling in inner thighs and in gluteal region 1 year back as she has taken  covid vaccine on that time and she consulted local doctor and recieved antibiotics ( amoxiclav 625mg/po/bd for 5 days and also herbal medicine for swelling local application it got relieved

Not a k/c/o hypertension, Tb,asthma, epilepsy, thyroid disorders

Menstrual history: 

Age of menarche: 13 years

Menses: regular,28 days cycle 

Flowincreased associated with clots and pain

Personal history:

Appetite: decreased

Diet: mixed

Bowel and bladder: regular

Sleep: adequate

Addictions: no

Family History: her father  is a known case of diabetes since 16 years and he was using insulin mixtard 2 times daily

General examination:

Patient was conscious, coherent, cooperative

Pallor: present

Icterus: absent

No cyanosis, clubbing, lymphadenopathy,edema

Vitals:

Temperature: 101 F

Bp: 120/70mmhg

PR: 92 BPM

RR: Tachyponeic at the time of admission

21cpm

Spo2: 98% on ra

Grbs:

On local examination:

Swelling was in perianal region which was initially 1x1 cms and progressed to present size of 4x4 cms

Pus discharge present

Skin over swelling: reddish colour

Palpation:

Tenderness+

Local rise of temperature

Induration of skin over the swelling+

Visible pus discharge

Pictures captured by Dr lohith pgy1

Incision and drainage of pus was done under spinal anaesthesia

After iand d of abscess picture:

On6/1/23:

On 7/1/23:

Systemic examination:

Respiratory system:

Position of trachea; midline

Position of Apex beat; left5ics 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movement of chest ; normal

 

Palpation ;

Position of trachea,apical pulse is confirmed

No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub

Percussion;

Resonant note heared,no obliteration on traubes space

Auscultation ; 

BAE-PRESENT, 

Per abdomen:

Per abdomen;

Shape; scaphoid

Umbilicus; central

Movements ; normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen ;normal

Palpation; soft non tender,

*  no tenderness,or local rise of temperature

Percussion ;

Liver; resonant note heared

No fluid thrills,shifting dullness

Auscultation;

Bowel sounds are heared

CVS:

Inspection;

Position of trachea ;midline

No visible pulsations,

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation; no palpable thrills,parasternal heaves are palpable

Percussion ; 

Auscultation; S1,S2 heart sounds are heared , 

CNS:

Higher mental functions intact

Reflexes- present

Power,muscle tone- normal

Gait- normal

No meningeal signs

Cranial nerves - intact

Investigations:

Hemogram:

       HB.     TLC     PC.   PCV  MCV. MCH  MCHC  

D-1 10.3  14,900 5.45l 34.7 70.   20.8.    29.7  

   

D-2 8.9.    12700 4.48  29.2 69.4 21.1.  30.5

D-3 9.7.  16700. 5.96. 31.4 68.3. 21.1. 30.9

D-4

 D-1 impression:.  microcytic hypochromic Anemia with neutrophilic leukocytosis and thrombocytosis

D-2: microcytic hypochromic Anemia with neutrophilic leukocytosis

CUE:

Appearance:

Albumin:++

Sugars:++

Pus cells:4-5

Epithelial cells:3-4

Urine for ketone bodies: positive

 

Urinary electrolytes:

Blood grouping and typing: O positive

LFT:

       TB.  DB.  AST.  ALT. ALP. TP.   Alb.  A/G

D-1 0.87 0.15 12.  16. 337.  7.1. 3.6. 1.13

D-2 2.04 0.47 18.  12.  293.   6.2. 3.2. 1.09

D-3 0.94 0.20 19   10. 276.  5.9. 2.99. 1.03

D-4

D-5

RFT:

    S.u.  S.cr.  Na.  K.  Cl.  I Ca.   Ca.  Mg.  P

D1 27. 0.6.  132  4.  102. 1.07

D-2 21. 0.6.  136. 3.4 106. 1.05

D3 22. 0.6.  135. 2.6. 108. 0.97

D4

D-5

RBs

FBS: 213

Plbs:

Hba1c: 7.6

Serology: negative

PT:

INR:

Aptt:

BT:2 min 30 secs

CT: 5 min 00 secs

 Serum osmolality: 297

Pus culture sensitivity:

On 18/1/23:

Klebsiella pneumonia isolated

USG abdomen:

Internal echoes noted in urinary bladder 

? Cystitis

Chest x ray:

2d echo:

No AR /MR/TR

No RWMA,No As/ps

Good lv systolic function

No diastolic dysfunction

No pAH/pe

Diagnosis:

Diabetic ketoacidosis with Type 1 DM since 6 years with perianal abscess

S/P : incision and drainage of abscess done under spinal anaesthesia ( 3/1/23)

Treatment:

Iv fluids Ns@100ml/hr

Inj Human Actrapid insulin Sc/TID

12u- 12u- 12u

Inj NPH sc/BD

15u- × -15u

Inj meropenam 1gm/iv/Bd d2

Inj Amikacin 500 mg/iv/Bd d2

Inj metrogyl 500 mg/iv/Tid d3

Inj pan 40 mg/ iv/ bd

Inj neomol 1 gm/iv/bd

Inj Tramadol 2ampoules in 100ml Ns/iv/bd

Inj Zofer 4 mg/ iv/bd

Inj kcl 20 meq in 100 ml Ns/iv /stat

Tab orofer xt/ po/ od @2pm

Tab Dolo 650mg/po/Tid

Sitz bath/ qid

Strict I/O charting

Grbs 7 print profile

6/1/23

: No fever spikes

    Stools passed