1801006023 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 :- 

https://drive.google.com/drive/folders/1EQ0MF_bwhLry8XJeksU9T8llMD5Pa_nm

No meningeal signs 

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 

Motor Pathway - 

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: Normal

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

PROVISIONAL DIAGNOSIS:- 

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

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

ECG

TREATMENT:-

Inj. OPTINEURON in NS 100 ml

Tab. ECOSPRIN

Tab. CLOPITAB

Tab. ATOROVAS

Tab. STAMLO BETA

Physiotherapy

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SHORT CASE

CHIEF COMPLAINTS

A 32 year old male patient presented with complaints of swelling of face, difficulty in swallowing and change in voice in February.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 16 years back, then in 2007 after exposure to cement dust he developed sudden difficulty in breathing, inability to speak, swelling of face , lips, hands and legs. Emergency tracheostomy was done and treated conservatively following which the symptoms were relieved. 

He was found to be allergic to smoke inhalation of burnt plastic, garbage, any offensive smell, strawdust and cotton.  

He is also allergic to foods like Brinjal, mutton, fish and papaya. 

The symptoms aggravated even on anxiety. Swelling of face increases after any H/O trauma.

Patient used to develop symptoms on and off from the past 16 years. Patient was referred to Outside hospital i/v/o immunotherapy in 2011 and was treated with some unknown medication and was advised precautionary measures against allergens. 

Again in 2016, patient was presented with some complaints as in 2007 when emergency tracheostomy was done, patient since then complains of occasional swelling of face, hand and legs which relieved on taking medication. 

In 2021, Patient presented with complaints of swelling of face and difficulty in breathing and was treated with FFP’s, adrenaline, nebulization, hydrocortisone and symptoms got relieved. Patient had around 6-7 hospital admissions in the past 16 years.

Done in 2020 December 

C4 complement serum is less than 8 mg/dl

C1 esterase inhibitor protein is 65 mg/dl

PAST HISTORY 

Not a k/c/o HTN, DM, CAD, thyroid disorders, epilepsy, TB

PERSONAL HISTORY 

Diet is mixed 

Appetite is normal

Sleep is adequate

Bowel and bladder movements are regular 

No addictions 

He is allergic to straw dust,burnt leaves, garbage, plastic smoke,

He is also allergic to foods like Brinjal, mutton, fish and papaya. 

FAMILY HISTORY

No significant family history

GENERAL EXAMINATION 

Patient is concious coherent and cooperative 

Perioral/lip edema present

Facial puffiness present 

Previous tracheostomy scar present on the neck

Vitals:

Temperature 98.6F

Pulse rate 106bpm

Respiratory rate 18per min

BP 110/70 mmhg 

Spo2 98 at room air 

GRBS 110mg/dl

SYSTEMIC EXAMINATION 

CVS 

s1s2 heard 

No murmurs

RS

Bilateral air entry present

Normal vesicular breath sounds

ABDOMEN

Soft, non tender 

No organomegaly

Bowel sounds heard 

CNS 

Power normal in bilateral upper and lower limbs 

Tone normal in bilateral upper and lower limbs 

Reflexes are normal 

No meningeal signs 

Pupils are reactive bilaterally 

PROVISIONAL DIAGNOSIS 

Angioedema 

TREATMENT

Following treatment was given during the patient’s hospital stay last month:

Inj hydrocortisone 100mg IV stat

Nebulization with adrenaline 1amp stat

Nebulization with budecort tid 

Nebulization with duolin qid 

Patient currently does not use any medication 

Patient used Tab Cetrizine and Prednisone on experiencing similar symptoms

INVESTIGATIONS

These investigations were done during the hospital stay last month 

CBP

Hb – 11.8

TLC – 16600

Neu – 90

Lymp – 06

PCV – 40.5

RDW – 18.2

RBC – 6.3

PLC – 5.3

BT – 2 min 30 sec

CT – 4 min 30 sec

APTT – 35 sec

PT – 18

INR – 1.33

CUE

Alb – trace

Pus cells -2- 3

RBS – 124

B.Urea – 32

S.Creat – 1.2

S.electrolytes

Na+ - 141

K+ - 3.9

Cl- - 105

Ca2+ - 1.11

LFT

TB – 0.89

DB – 0.20

AST- 21

Alt -16

ALP-124

T Protein – 7.3

Albumin -4.59

A/G -1.69