1801006057 CASE PRESENTATION
LONG CASE
CHEIF COMPLAINTS
50 Years old male ,resident of miryalaguda,works in ice factory, came with chief complaints of right sided weakness (upper limb and lower limb) , deviation of mouth to left side and slurring of speech since 2 days (12/3/2023 at 4 am).
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1month back then he developed giddiness and weakness in left lower limb and left upper limb. so he went to the hospital in miryalaguda , there he diagnosed with hypertension,they gave antihypertensives (amlodipine and atenolol).
His left sided weakness was resolved in 3 days.
Then he took the antihypertensives for 20 days and after that he stopped medications since 10 days onwards because his friends told that take alcohol it will resolves the weakness of limbs.
So he stopped medications and took the alcohol since 10 days.
On 11th March 2023 night he took alcohol and slept , on 12 March 2023 at 4am he woke up but he developed giddiness, unable to stand due to weakness in the right upper and lower limbs, deviation of mouth to left side and slurring of speech. So he was taken to the miryalaguda hospital there he underwent CT scan then they referred to our hospital.he came to our hospital on 13 March 2023
There is no history of difficulty in swallowing, behavioural abnormalities, fainting, sensory disturbances, fever, neck stiffness, altered sensorium, headache, vomiting, seizures, abnormal movements, falls.
DAILY ROUTINE:
Daily he wake up at 5:00am does his morning routine and drinks tea and goes to work ,at 9 '0 clock he comes to home and have breakfast and goes to work till 2 pm and will have his lunch at home ,he then again goes to work till 9pm returns home will have his dinner and sleeps at 10pm.
PAST HISTORY
Fracture near the right elbow due to fall from the tree 30 years ago ,so he cannot extending his right hand completly.
He is a known case of hypertension since 1 mn.
Not a k/c/o Diabetes,asthma, coronary artery diseases,epilepsy,thyroid disorders.
PERSONAL HISTORY
Diet- mixed
Appetite - normal
Sleep -normal
Bowel and bladder -regular
Addictions-
-He is chronic alcoholic since 20 years, stopped 3 years back but again started 6 mns back after death of his daughter's husband.
-he chews tobacco since 10 years (1 packet per 2 days).
FAMILY HISTORY
No similar complaints in the family.
TREATMENT HISTORY
He is on antihypertensives (amlodipine and atenolol) since 1mn but 10 days onwards he stopped medications.
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
SYSTEMIC EXAMINATION
1:) CNS EXAMINATION-
Dominance - Right handed
HIGHER MENTAL FUNCTIONS
• conscious
• oriented to time,person and place
• memory - immediate,recent,remote intact
•slurring of speech
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 left side and right 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
POWER
Rt UL - 4/5 Lt UL-5/5
Rt LL - 4/5 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: - Flexion
Involuntary movements - absent
Fasciculations - absent
SENSORY SYSTEM
Light touch ,pressure, tactile sensation, pain , temperature, vibration , position sense are normal
-two point discrimination -able to discriminate
-tactile localisation -able to localis
CEREBELLUM :
Finger nose test normal,
no dysdiadochokinesia,
Rhomberg test could not be done
AUTONOMIC NERVOU SYSTEM - normal
• MENINGEAL -no meningeal sign
Gait:
ABDOMINAL EXAMINATION
INSPECTION:
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible
pulsations.
PALPATION
soft, non-tender
no palpable spleen and liver
PERCUSSION
- live dullness is heard at 5th intercoastal space
AUSCULTATION- normal bowel sounds heard.
CARDIOVASCULAR SYSTEM
INSPECTION
Shape of chest- elliptical
No engorged veins, scars, visible pulsation
PALPATION
Apex beat palpable in 5th inter costal space
No thrills and parasternal heaves can be felt
AUSCULTATION
S1,S2 are heard
no murmurs
RESPIRATORY SYSTEM
INSPECTION
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
PALPATION
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
PERCUSSION: resonant bilaterally
AUSCULTATION
bilateral air entry present. Normal vesicular breath sounds heard.
PROVISIONAL DIAGNOSIS
Cerebrovascular accident with Right sided hemiparesis due to involvement of posterior limb of internal capsule.
INVESTIGATIONS
•13/3/2023
*Blood sugar random - 109 mg/dl
*FBS - 114 mg/dl
*Complete blood picture:
Hemoglobin- 13.4 gm/dl
WBC-7,800 cells/cu mm
Neutrophils- 70%
Lymphocytes- 21%
Esinophils- 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
hloride - 104 mEq/L
Calcium ionised - 1.02 mmol/L
*Anti HCV antibodies rapid - non reactive ;
*HIV 1/2 rapid test - non reactive
*MRI
65 yr old male from Nalgonda farmer by occupation came to the hospital for maintenance dialysis
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 20 years back then he noticed yellowish discolouration over sclera and urine and decreased urine output then he went to a hospital.Investigations are done and diagnosed as Jaundice.
At the same time he also diagnosed as right kidney damage. so that 3 episodes of dialysis was done in a week.
For the next 10 years he was normal.
After 10 years he went for a normal check up and he diagnosed with diabetes and Hypertension.From then he is on medications.
For 8 years he is on oral diabetic drugs.And from 2 years he is on insulin.( Human Actrapid insulin along with Lantus )
2 months back he came to the hospital with decreased urine output and pus the urine, SOB (grade 1), back pain . For which he came to know that there is left kidney damage. From then he is on dialysis twice a week. Till now 13 episodes are done.
3 days back there is decreased urine output, back pain for which he came to the hospital.
PAST HISTORY
Known case of Diabetes and Hypertension since 10 years
PERSONAL HISTORY
Routine history :He wakes up at 6 am in the morning and eats breakfast at around 9 am and works as shopkeeper and then lunch at 1pm takes a nap in the afternoon. Drinks tea in the evng and chapathi as dinner at 8 pm. Sleeps at 10 pm.
Diet : Mixed
Appetite: Good
Bowel and bladder movements: Regular
Sleep : Adequate
Addictions : Consumption of alcohol since 40 years and stopped 15 years back
No smoking.
GENERAL EXAMINATION
Patient was conscious, cooperative.Moderetly built and nourished.Well oriented to time, place and person.
pallor present
No icterus
No Cyanosis
No clubbing
No generalized lymphadenopathy
Pitting Pedal edema present
VITALS
Temperature ; afebrile
RR;20cycles/min
PULSE;80bpm
GRBS;210mg%
Spo2; 100 at room temperature
BP; 130/80 mm Hg
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
s1 and S2 are heard ,no murmurs are heard
RESPIRATORY SYSTEM
trachea central,
all quadrants of chest moves equally with respiration.
Breath sounds- bilateral normal
Vesicular breath sounds are heard.
CENTRAL NERVOUS SYSTEM
Patient was conscious, coherent and cooperative
Speech was normal.
No slurred speech.
ABDOMINAL EXAMINATION
Inspection:
On inspection abdomen is flat, symetrical,and slightly distended.
Umbilicus is centre and inverted
No scars,engorged veins are seen.
All 9 regions of abdomen are equally moving with respiration.
Palpation:
On palpation abdomen is soft and non tender
.On bimanual examination of kidney is not palpable.All inspectory findings are confirmed.
Percussion:no shifting dullness, no fluid thrills
.
Auscultation:normal bowel sounds are heard.
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS: CKD
Treatment:
Salt restriction less than 2.4 gm /day
Fluid restriction less than 1 litre/day
Tab Nodosis po/Bd
Tab shelcal po/Bd
Orofer XT po/bd
Tab Lasix po/Bd
Tab biop3 weekly once.
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