H/o cough on intake of liquids.
H/o change of voice since 20 days, insidious, hoarse in character and
SLURRING OF SPEECH +present
No h/o difficulty in breathing, breathlessness, hemoptysis
Fever since 10 days -high grade. O/e Chills and rigors + (38 spikes).
N/h/o vomiting, chest pain, loose stools.
7 YEARS BACK:(2016)
He developed head ache at around afternon 2pm and followed by vomtings and left hand itching and weakness.
PATIENT is awake on that night due to left hand weakness and itching
NEXT DAY
MORNING they took him to hospital
Patient can lift his hand
But unable to hold objects
AFTER 3 DAYS
PATIENT became left sided hemiplegia.
MRI REPORT- 3 INFARCTS
Patient stayed for 40 days in hospital and there was no improvement and discharged.
He took liquids for 3months because patient is unable to eat solid foods.then he slowing started eating solid foods.
AFTER 1 YEAR (2017):
vomitings
Fever
Shivering for 3 days
Diagnosed with urinary tract infection
Took treatment (antibiotics) for 5 days and it resolved
AFTER 3 YEARS:(2020)
Cough for 2days
Fever on 2nd day
Diagnosed with covid
He got COVID for 1st time and resolved
After 1 year(2021)
He was Diagnosed with COVID for 2nd time and resolved
1 YEARS back (2022)
He got seizures for 5min and they took him to the hospital.
He got Typhoid fever 2times
1st time resolved in 7days
2nd time resolved in 9 days
79 Year old male who is a father of 4 children ( 2 sons and 2 daughters)..was used to run shop ( kirana shop) for about 18 years.He stopped looking after his shop from 2006 and he was looked after by his son's.
He was non alcoholic,non smoker.
10 years back , patient developed lesions on his both foot and went to the doctor and found to have diabetes and started on medication.and after 1 year ,with regular check up he was found to be Hypertensive and started on antihypertensive medication.
From 7 years onwards , patient was bedridden with foleys ( changed every 15 days ) and physiotherapy was done by his attenders daily, but there was no such improvement
PAST HISTORY
Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is on medications I.e tab TELMA AM 40mg po/od. Tab zoryl mv , po/od
PERSONAL HISTORY
Appetite lost,
Mixed diet
Bowel- constipated,
Bladder regular
No known allergies and Addictions.
i.e non alcoholic and non smoker
Family History- not any
Treatment history
•Tab TELMA AM 40mg po/od since past 10years
•Tab zoryl mv , po/od
•Tab levipil 500mg since 2 years
• thyronorm 25mcg. Since5 years
GENERAL EXAMINATION
On examination patient is arousable but not oriented.
Pt not cooperative mostly.
-PALLOR:PRESENT
NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
VITALS ON ADMISSION
PR-90 BPM
BP- 140/80MM HG
RR- 22 CPM
SPO2- 98% AT RA
GRBS - 183mg/dl
SYSTEMIC EXAMINATION:
Respiratory :-
Inspection : respiratory movements equal on both sides
Trachea central
palpation : apical impulse in left 5th intercostal space
Auscultation : normal vesicular breath sounds
Percussion- BAE+
CNS
PATIENT is unconscious incoherent uncooperative
HIGHER MENTAL FUNCTIONS- cannot be elecited
Speech
Behaviour
Memory
Intelligence
Lobar functions
B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT
NO SIGNS OF MENINGEAL IRRITATION,
CRANIAL NERVES
2nd cranial nerve
Visual acuity is decreased on left side
3rd 4th 6th pupillary reflex present
SENSORY SYSTEM- cannot be elicited
Spinothalamic sensation:
Crude touch
Pain
Temperature
Dorsal column sensation
Fine touch
Vibration
Propioception
Cortical sensation
Two point discrimination
Tactile localisation
Stereognosis
Graphathesia
MOTOR EXAMINATION:
Right n left
UL. LL. UL. LL
BULKv Normal Normal Reduced
TONE Normal Hypotonia
POWER Could not be elicited.
SUPERFICIAL REFLEXS
plantar reflex
Left side babinski sign positive
iv>
DEEP REFLEXES:
BICEPS, TRICEPS, SUPINATOR, KNEE ANKLE.
CEREBELLAR EXAMINATION cannot be elicited
Finger nose test
Heel knee test
Dysdiadochokinesia
Dysmetria
hypotonia with pendular knee jerk present.
Intention tremor present.
Rebound phenomenon .
Nystagmus
Titubation
Speech
Rhombergs test
SIGNS OF MENINGEAL IRRITATION: absent
GAIT: patient unable to walk
CVS
ASCULTATION: S1S2 +,NO MURMURS
P/A
INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS
AUSCULTATION: no bowel sounds heard
bed sores
C/o asymptomatic lesions all over the body since 2 months
H/o application of unknown topical medications used
O/e multiple hyperpigmented Macclesfield present all over the body with scaly lesions over the upper back
•Diffuse xerosispresent
• single ulcer of size 1.5x1.5 cms (approx) over the back.
Diagnosis SENILE XEROSIS + post inflammatory hyperpigmentation.
( +? TROPHIC ULCER )OBSERVATIONS:
• Large area of encephaolomalacia in right occipito -temporo lobes and righ parietal lobes.
• Prominence of sulci and cisterns.
• Bilateral periventricular hyperintensity.
• Rest of the Cerebral parenchyma shows normal gray/white matter differentiation.
• Basal ganglia and Thalami are normal.
• Brain stem normal.
• Cranio-vertebral and Cervico-medullary junctions are normal.
• Sella, pituitary and parasellar regions are normal. Stalk and hypothalamus are normal. Posterior pituitary bright spot is normal.
• No evidence of abnormal calcifications, vascular anomalies on SWI sequences.
IMPRESSION:
• Large area of encephalomalacia in right occipito-temporo lobes and right parietal lobes - sequelae of old infarct.
• Diffuse cerebral atrophy. Chronic small vessel ischemia.
Note: Poor quality of images due to motion artefacts
CUE :-
AFB-TRACE
PUS CELLS -2-4
EPITHELIAL CELLS -2-3
LFT
INVESTIGATIONS:
Anti HCV antibodies rapid -nonreactive
Blood urea -30mg/dl
HBA1C-6.7%
HbsAg rapid - negative
HIV 1/2 RAPID TEST - NON REACTIVE
TOTAL BILIRUBIN -0.81mg/dl(normal-0 to 1mg/dl)
Direct bilirubin-0.17mg/dl(0 to 0.2mg /dl)
Serum creatinine -0.9 mg/dl (0.8 to 1.3 mg /dl)
ABG
Ph 7.51
PCO2 29.5mmhg
Po2 67.5 mmhg
Electrolyte
Sodium 135meq/l
Potassium 3.5 meq/l
Chloride 98meq/l
Calcium -1.06 mmol/l
PROVISIONAL DIAGNOSIS
Recurrent CVA with Hypertension, T2 DM, seizures disorder.
TREATMENT
1) TAB ECOSPRIN 150 mg RT/OD
2) TAB CLOPIDOGREL 75 MG RT/OD
3) TAB ATORVAS 20 MG RT/OD
4) NEBULISATION - 3% NS ,
MUCUMZY 8th hourly
5) CHEST PHYSIOTHERAPY.
6) RT FEEDS 100 ML WATER 2nd HRLY
50 ML Milk 2nd HRLY.
8) TAB. THYRONORM 25MCG RT/OD
9) TAB. LEVIPIL
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SHORT CASE
A 60 years old female came with cheif complaints of
Neck pain and headache since 5 years
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 10 years ago. She then complained of back pain which is insidious in onset and gradually progressive. There are no aggravating or relieving factors. She then developed a head injury due to a heavy object (bottle gourd) falling on her head.
5 years ago she developed fever which was associated with pain in multiple joints and was diagnosed with Chikungunya. Following the episode the joint pains persisted and the patient complained of pain in multiple joints which started in the fingers and wrist and progressed to all the joints. The pain in the joints is greater when she wakes up and is associated with stiffness. The stiffness is relieved on activity.
Her neck pain also started around 5 years ago and is associated with pain in the right nuchal and occipital region and the right shoulder. The pain is temporarily relieved on using topical and oral analgesics.
2 years ago she visited the hospital due to an episode of fever and was incidentally diagnosed with Diabetes. She also complained of weight loss in the last 2 years around 10 to15kg.
1 year back she couldn’t raise her right arm and had increased severity of back pain for which she was advised MRI and she was informed about spine degeneration. Due to limitation of movement she was given injection to her right shoulder joint and after 10 days followed by injection to knee joint.
Patient now presented with increased severity of headache and neck pain which is radiating to right shoulder. It is associated with difficulty in moving head from side to side, pain on moving head and there is presence of heaviness in head.
There is no history of fall, fever, vomiting and shortness of breath.
PAST HISTORY:-
She is known case of hypertension from past 20 years.
Diabetes mellitus from past 2 years.
She had hysterectomy 30 years ago.
No history of asthma, TB, epilepsy, any thyroid abnormalities.
PERSONAL HISTORY:-
( daily routine )
She lives in a joint family with 10 members in the family. She live with her husband along with her 3 sons and her daughters in law. She used to work as a daily wage worker but from past 4 years she is not working due to the pain and discomfort.
She daily cooks for her family members.
Her sleep is inadequate due to pain and discomfort. She sleeps at 1am at night and wakes up at 4am in the morning.
She mainly consumes vegetarian food, which mainly includes millets, chapatis and any veg curries.
Her appetite is normal.
Her bowel and bladder movements are regular.
She used to consume toddy and alcohol but stopped 2 years ago.
She consumes tobacco daily to relieve her tooth pain from past 3 years.
She has no known allergies.
TREATMENT HISTORY:-
She consumes tab. Losartan + hydrochlorthiazide for hypertension from past 20 years.
Tab. Metformin for Diabetes from past 2 years.
FAMILY HISTORY:-
No similar complaints in the family.
GENERAL EXAMINATION:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Moderately built and moderately nourished.
Vitals :-
Temp - afebrile
BP - 130/80 mm Hg
Pulse rate - 78 bpm
Respiratory rate - 14 cycles per minute
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Oedema - absent
SYSTEMIC EXAMINATION:-
1) CVS examination:-
- S1 S2 heard
- no murmurs heard.
2) Abdominal examination:-
Abdomen is soft and non tender
No organomegaly
No shifting dullness
No fluid thrill
Bowel sounds heard
3) 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.
4) CNS examination :-
- No focal neurological defects
- All cranial neves are intact.
- No meninges signs
Glasgow scale- 15/15
Power:-
Rt UL-5/5. Lt UL-5/5
Rt LL-5/5. Lt LL-5/5
Tone:-
Rt UL -N
Lt UL-N
Rt LL-N
Lt LL-N
Reflexes: Right Left.
Biceps. ++. ++
Triceps. ++ ++
Supinator. + +
Knee. ++ ++
Ankle. + +
Plantar: Flexion Flexion
PROVISIONAL DIAGNOSIS:-
Neck pain under evaluation, could be due to rheumatoid arthritis?
with Diabetes type II and Hypertension
INVESTIGATIONS
Blood urea:
CRP:
Complete urine examination:
HEMOGRAM:
LFT:
Serum electrolytes:
Serum creatinine:
HIV:
Hepatitis B:
Hepatitis C:
TREATMENT:-
Strict diabetic diet
Tab. ULTRACET 1/2 tab PO/ QID
Tab. SULFASALAZINE 1gm PO/ OD
Tab. METFORMIN 500mg PO/ OD
Tab. LOSACURE 50 PO/ OD
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