1801006016 CASE PRESENTATION

Long case

Case:

This is a case of 55 year old male with chief complaints of

- deviation of mouth to left side since 2 days (11/03/2023)

- slurring of speech since 2 days

History of presenting illness:

Patient was apparently asymptomatic 2 days ago.

He then developed slurring of speech which was sudden in onset.He also developed bilateral blurring of vision which was sudden in onset and which lasted for an hour.On the same day his wife noticed deviation of mouth to left side and was taken to local doctor for which he was given ORS but the symptoms had not subsided.

The next day his wife took him to another doctor for which he was given ORS again.

On 13/03/2023 he came to the our hospital.

At the time of presentation

- slurring of speech had decreased

-slight deviation of mouth was present

No weakness of upper and lower limb

No h/o loss of consciousness

No drooping of eyelids

No drooling of saliva

No difficulty in swallowing

Daily routine:

Patient is a farmer by occupation resident of yadgirigutta.

Patient wakes up at 5am in the morning and does his daily work and prays for an hour.

He has rice for breakfast by 8 am.

He goes to the fields along with his wife on scooty by 9am.

He has his lunch by 1pm.

In the evening they return from work at 6pm.

He goes for bath and has his tea.

He has rice for dinner at 8pm and prays for an hour.

He goes at bed at 10pm.

Past history:

No history of similar complaints in the past.

Patient is a known case of Hypertension since 1 year and does not take his medication regularly.

History of tuberculosis 21 years ago and was on medication for 6 months.

History of perforation to tympanic membrane 21 years back for which he has been using a hearing aid.

Not h/o Diabetes,asthma,epilepsy

Personal history:

Diet: mixed

Apetite: normal

Sleep: disturbed

Bowl and bladder: regular

Addictions: drank sara when he was 23 years and stopped when he was 30 years.

Family history:

Father is a known case of Diabetes Hypertension and Tuberculosis

Mother passed away due to breast cancer

Both the sons of the patient were also affected with tuberculosis at the same time

Both his sisters are known case of diabetes and Hypertension

Brother , sister in law,and both their children were affected with tuberculosis.

Brother had history of stroke 3 years back.

General examination:

Patient is conscious,coherant,cooperative,moderately built and moderately nourished.

Pallor:absent

Icterus:absent

Cyanosis:absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent

Vitals:

Temperature: afebrile

Pulse: 60 beats per minute

Blood pressure: 130/80 mmHg

Respiratory rate: 18 cycles per minute

Systemic examination:

CNS:

- Higher mental functions

conscious,coherent and cooperative
memory- able to recognize his family members
Speech - comprehension present, no fluency, repetition present

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, forehead wrinkling present , nasolabial folds prominent on both sides.
VIII- Vestibulocochlear nerve- decreased hearing of the left ear ( rinner’s negative for 256 Hz and 512 Hz) and normal hearing of the right ear
IX- Glossopharyngeal nerve- palatal movements present and equal
X- Vagus- palatal movements present and equal
XI- Accessory nerve- sternocleidomastoid contraction present
XII- Hypoglossal nerve- deviation of tongue to right side and no fasciculations present

-Sensory system examination:

Right Left

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

R Right. Left

Motor system examination

BULK: U/L- arm 28cm 29cm

-forearm 27 cm 26cm

L/L- thigh 49cm 49cm

- leg 33cm 31cm

TONE: U/L normal normal

L/L Normal normal

Right Left

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

elbow 5/5 5/5

- shoulder 5/5 5/5

L/L- hip 5/5 5/5

- knee 5/5 5/5

- ankle 5/5 5/5

Right Left

REFLEXES: Biceps ++ ++

Triceps ++ ++

Supinator ++ ++

Knee ++ + +++

Ankle + +

Plantar Flexion Flexion

Gait: normal

CVS: S1 & S2 heard. No murmurs

Respiratory system:Normal vesicular breath sounds heard Abdomen: Soft and non-tender.No organomegaly

Investigations:

Complete blood picture

Haemoglobin:11.7

Peripheral smear: normocytic normochromic anemia

Red blood cells:3.86

Pcv:34.6

Platelet count:2.10

Total leucocyte count:5,100

Fasting blood sugar : 92 mg/dl

Serum creatinine :1.3 mg/dl

Blood urea 38 mg/dl

CUE:

Colour : pale yellow

Appearance : clear

Reaction :acidic

Albumin:nil

Sugar: nil

Bile salts and bile pigments : nil

RBC : nil

Crystals :nil

Casts : nil

pus cells:2-3

epithelial cells-2-3

Serum electrolytes

Sodium: 145 mEq/L

Potassium:4.2mEq/L

Chloride:104 mEq/L

Calcium ionized:1.11 mmol/L

ECG:

MRI:

2D ECHO:

Ophthalmology referral:

DRUGS:

Provisional diagnosis:

Cerebrovascular accident

With acute infarct in left internal capsule

With acute infarct in left occipital lobe

Treatment:

INJ. OPTINEURON 1 AMP IN 500ML

NS IV OD

TAB. CLOPITAB 75 MG PO/OD

TAB. ECOSPRIN AV 75/10 PO

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short case

A 49 year old female came with chief complaints of pain in the joints since 10 years.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 years back.She then developed fever (on and off type) for which she takes paracetamol (2-3 everyday).She had 2-3 episodes of vomiting,headache and increased frequency of micturation(15-20 times a day).

She then developed pain and swelling in her wrist,ankle,shoulder,elbow,hip,metacarpal phalanges,metatarsal joints and lower back which is radiating to both her legs till feet for which she was taken to the hospital.The medication prescribed to her provided her temporary relief.

She also complaints of pedal edema and stiffness in the joints as soon as she wakes up in the morning.

She has stopped her medication one month back.

DAILY ROUTINE:

She wakes up at 6:00 am in the morning.She takes a head shower everyday as she believes that it reduces her headache.She does the household chores,gets groceries and cooks food.She works at her farm from afternoon to evening and occasionally sells the produce in the market.Later in the night she cooks dinner and sleeps by 8:00pm.

PAST HISTORY:

Not a known case of Diabetes mellitus,Hypertension,Asthma,epilepsy

PERSONAL HISTORY:

Diet: used to have a mixed diet but now she stopped consuming meat

Apetite: decreased apetite

Sleep: reduced

Increased frequency of micturation(15-20 times a day)

Addictions: none

GENERAL PHYSICAL EXAMINATION:

Pallor:present

Icterus:absent

Cyanosis:absent