1801006059 CASE PRESENTATION

LONG CASE

 A 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 B/L 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.

Personal history:

Diet: mixed

Apetite: normal

Sleep: disturbed

Bowl and bladder: regular

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

Family History-

Father is a known case of Diabetes Hypertension and Tuberculosis and he passed away due to COVID.

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:absenti

Vitals:

Temperature: afebrile 

Pulse: 60 beats per minute

Blood pressure: 130/80 mmHg

Respiratory rate: 18 cycles per minute

Systemic examination:

CNS:

  

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                                                                                    Motory system examination

                                                Rt.           Lt.

 BULK:       U/L- arm           28cm     29cm                                   

                        -forearm     27 cm     26cm   

                                      

                 L/L-   thigh         49cm       49cm

                         - leg            33cm         31cm

                  

       TONE :      U/L        Norrmal      normal                       

                        L/L          Normal       normal

                                        Right              Left     POWER: 

 U/L-   Arm                  5/5                  5/5

        Ĥ    Forearm          5/5                 5/5

                                   

   L/L     Hip                 5/5                5/5

             - knee             5/5                 5/5   

             - ankle             5/5                5/5

REFLEXES-

                                   Right              Left         Biceps                       ++                  ++

 Triceps                     ++                  ++

                                                                    

 Knee                       ++                 +++

 Ankle                       +                    +

 Plantar               Flexion               Flexion

Gait.- Normal

Triceps

Biceps

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:3.86u

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 

Calcium ionized:1.11 mmol/L

ECG:

MRI :

2D ECHO:

https://youtube.com/shorts/J_NReYstBi8?feature=share

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

IVF NS IV OD 

TAB. CLOPITAB 75 MG PO/OD

TAB. ECOSPRIN AV 75/10 PO/OD

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

SHORT CASE

A 30yr old male patient came with Chief complaints of  Pain Abdomen and Vomiting with clots .

HOPI: Patient was apparently asymptomatic 2 yrs back, later he developed burning  type of pain in epigastric region when he consumes alcohol and on eating spicy food. He also had  1 or 2 episodes of vomitings along with pain  which were clear or sometimes yellowish in color .

He came to KIMS around 6 to 8 times in 2 years for the above complaints and has been treated for the cause and was advised to stop consuming alcohol.

3 months back ,he  had an episode of vomiting with smal amount of clots(1- 2 )  with severe epigastric pain with was stabbing and  severe burning sensation in the throat after the 

He came to the hospital with 

7 to 8 episodes of vomit with blood clots which were black in color with pain abdomen which was severe stabbing and non radiating type.

He also had a single episode of vomiting which was greenish in color  on the same day.

*Symptoms aggravated by intake of spicy food and alcohol.

No H/O -Fever,headache,diarrhoea,blood in stool,body pains, burning micturition.

PAST HISTORY:

No H/O - DM,HTN,T.B,Epislepsy,Asthma,Syphilis,CAD,and CKD.

No known history of drug allergies.

FAMILY HISTORY -Nothing Significant.

PERSONAL HISTORY

**Diet: Vegetarian Bland food .(Since the episodes of vomiting and pain)

**Appetite: Decreased 

Bowel and Bladder movements :Regular

Sleep: Adequate

**Addictions: Alcohol intake of 90-190ml /day since past 10 years And Tobbacco chewing since

9years.

ON EXAMINATION

Patient was conscious, coherent, cooperative and we'll oriented to time place and person

GENERAL PHYSICAL EXAMINATION

Pallor-absent 

Icterus- absent

Cyanosis- absent

Clubbing- absent

Generalized lymphadenopathy- absent

**Vitals**

Temperature- Afebrile

Pulse rate -80bpm

Respiratory Rate - 18cpm

Blood pressure-128/85mmHg

sPo2 97% at room temperature

SYSTEMIC EXAMINATION

CVS: Inspection

Chest wall is bilaterally symmetrical.

No precordial bulge is seen 

Palpation

JVP- Normal

Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 

Auscaltation-

S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM

Position of trachea- central

Bilateral air entry, normal vesicular breath sounds are heard.

No added sounds

CVS

Patient is conscious ,coherent and co operative , well oriented to time and space.

Speech normal.

No signs of meningeal irritation.

Motor and sensory system- Normal

Reflexes - present

Cranial nerves - intact

PER ABDOMEN

On inspection:

Abdominal distention - absent

All quadrants are moving equally with respiration

Umbilicus - central and inverted

No scars,dilated veins, prominent Venous pulsations and visible pulsations.

On palpation::

Superficial palpation- No Local rise in temperature and no tenderness

Deep palpation- No guarding, rigidity

#TENDERNESS felt over left hypochondrium and epigastrium region

On percussion::

Tympanic note - heard 

No shifting dullness

On auscaltation::

Bowel sounds heard 

PROVISIONAL DIAGNOSIS::

Upper GI bleed secondary to esophageal varices 

Known case of Chronic pancreatitis and 

Alcoholic gastritis.

INVESTIGATIONS:

Heamogram::

Hb-14.5gm/dl

TLC-6700 cells/cumm

Lymphocytes-38

Eosinophils-**10**

Platelet count-1.40lakhs/cumm

TREATMENT::

Inj.PANTOP 80mg in 40ml of NS

Inj.THIAMINE 200mg

Inj. ZOFER 4mg

Inj. TRENIXA 500mg

Inj.Diclofenac.