1801006102 CASE PRESENTATION
long case
Case discussion
A 50 year old male presented to the casualty with weakness of right upper and lower limbs since the morning of 13/3/23 4am. With slurring of speech and deviation of mouth to the left side.
History of presenting illness
Patient was apparently asymptomatic 1 month back, he later developed giddiness followed by a fall. He was diagnosed with hypertension( HTN) to which he used medication for 20 days and stopped 10 days ago.
He was asymptomatic until yesterday when he noticed weakness in his right upper and lower limbs while going to the washroom. It was associated with deviation of the mouth to left side and slurring of speech. Symptoms were sudden in onset and quick in progression.
There is history of (H/O) trauma
There is no H/O difficulty in swallowing, giddiness, headaches, nausea, vomiting, drug intake, chest pain, drug intake, tingling sensation of effected limbs.
Past history
Diagnosed with HTN one month back.
H/O past trauma
No H/O diabetes mellitus, epilepsy, tuberculosis, coronary artery disease, thyroidal illness, HIV, malignancy, fever, drug intake
No previous hospital admissions
Personal history
Diet- mixed
Appetite- normal
Bowel and bladder- regular
Sleep- adequate
Addictions- consumes alcohol( average of 90ml per day)
Family history- no relevant family history
Treatment history-
General examination
Consent of the patient was taken
Patient is conscious, coherent and cooperative
Well built and nourished
pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing:absent
Lymphadenopathy: absent
Edema: absent
Temperature: 98°F
Pulse:60 beats/ minute
Blood pressure: 140/80mmHg
Respiratory rate: 14 cycles/minute
No involuntary movements
No abnormal neck swellings
No neck stiffness present
Systemic examination
CENTRAL NERVOUS SYSTEM
*Higher mental functions
Patient is conscious
Oriented to time place and person
Well dressed, well behaved and in a good mood
Speech slightly slurred, language understandable
Memory: intact
*Cranial nerves
Olfactory nerve: smells perceived
Optic nerve: counting fingers 6m
III, IV, VI: ocular motility normal, pupillary reflexes normal
Trigeminal nerve: jaw jerk present, corneal reflexes present
Facial nerve: mouth deviated to the left side
Vestibulocochlear nerve: normal sensory hearing
IX, X: no difficulty in swallowing
Accessory nerve: neck movements normal
*Motor system
No muscle wasting
Normal muscle tone
Power: upper limbs- right 3/5. Left-5/5
Lower limbs- right 0/5. Left- 5/5
Reflexes. Right. Left
Supinator- 3. 3
Biceps. 3. 3
Triceps. 3. 3
Knee. 3. 3
Ankle Extensor. Extensor
Coordination
Finger to nose- present on right side
Dysdiadochokinasea- present on right side
Knee to hell- uncoordinated on the right side
Sensation- pain, temperature, proprioseption, vibration felt equally on both sides
Gait- unable to walk without support, dragging legs
Rombergs test- couldn’t be elicited
CARDIOVASCULAR SYSTEM.
*Inspection- normal shape, bilaterally symmetrical, no percardial bulge, no engorged veins
*palpation- apical beat felt at 5th inter coastal space, no additional pulsation felt, no thrills felt
*percussion- heart borders noted
*auscultation- S1 and S2 heard. No additional heart murmurs
ABDOMEN
*inspection- flat abdomen with no distension, no engorged veins visible, skin over abdomen normal, umbilicus central, hernial orifices normal, external genital normal.
*palpation- no tenderness present, temperature to touch normal, no abnormal swellings.
*percussion- tympanic sound with dullness over solid organs
*auscultation- bowel sounds heard.
RESPIRATORY SYSTEM
*inspection-chest normal shape and bilaterally symmetrical
*palpation-trachea midline, chest movements symmetrical, tactile and vocal fremitus felt
*percussion- no dullness present bilaterally
*auscultation: Normal vesicular breath sounds heard, no added sounds.
Diagnosis: Cerebrovascular accidentwith right hemiparesis.
Investigations:
Haemogram:
Haemoglibin 13.4
Total lecucocyte count 7,800
Red blood cells 4.45
Platelets- 3.01
Complete urine examination
Pale yellow clear
Acidic
Trace albumins
Pus cells 3-4
Epithelial cells 2-3
Sugars nil
Thyroid function tests
T3 0.75
T4 8
TSH 2.18
Renal function test
Urea: 19mg/dl
Serum. Creatinine: 1.1mg/dl
S. Na+: 141 mEq/L
S. K+:. 3.7 mEq/L
S. Cl-: 1.02 mmol/L
FASTING BLOOD SUGAR: 114mg/dl
ECG
Treatment:
1. TAB. ECOSPRIN 150 MG PO/STAT
2. TAB. CLOPITAB 150 MG PO/STAT
3. TAB. ATORVAS 80 MG PO/STAT
4. PHYSIOTHERAPY OF UPPER AND LOWER LIMB
5. I/O CHARTING
6. VITALS MONITORING
7. INJ. OPTINEURON IN 1 AMP IN 500ML NS IV/OD
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short case
CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS
Case discussion:
A 56 year old female presented to the casualty with complaints of pain in abdomen since 10 days, fever and burning micturition since 2days.
History of presenting illness
Patient was apparently asymptomatic 10 days back and later she developed abdominal pain which was sudden in onset and rapid in progression. The pain was of a dull and persistent type radiating to the right shoulder and back. There were no aggregating and relieving factors.
There is history of (H/O) nausea, loss of appetite
There is no H/O vomitings, loose stools, abdominal rigidity.
Two days ago she developed fever which was low grade, intermittent, associated with chills and rigors.
Fever subsided on taking medication.
There is no H/O vomitings, loose stools, previous infections.
Past history
No similar complaints in the past
Patient is diagnosed of Hypertension (HTN)
No H/O diabetes mellitus, epilepsy, tuberculosis, thyroidal illnesses, tuberculosis, maignancies, cardiovascular disease.
No previous history of hospitalisation and surgeries.
Personal history
Diet- Mixed
Appetite- decreased
Bowel and bladder- regular
Sleep- adequate
Addictions- consumes Toddy occasionally
Family history - All 4 children ( 2 sons and 2 daughters ) diagnosed with HTN
Treatment history- Tab. Telmisartan 40mg daily.
General examination-
Consent of patient taken
Patient is conscious, coherent and cooperative.
Well built and nourished
Pallor- absent
Icterus- absent
Clubbing- absent
Cyanosis- absent
Lymphadenopathy- no palpable lymph nodes
Edema- pitting type edema present over the extremities of the lower limb
Temperature: 102°F
Pulse:74 beats/ minute
Blood pressure: 110/70 mmHg
Respiratory rate: 20 cycles/ minute
Systemic examination
ORAL CAVITY: lips, buccal mucosa, teeth, tongue, palate, tonsils, posterior pharyngeal wall normal and hygiene maintained
ABDOMEN:
Inspection -
Shape scaphoid and distended uniformly
Flanks are free and full
Umbilicus central and everted
Skin on abdomen smooth with no visible veins and stretch marks
No dilated veins
No visible peristalsis
Hernial orifices free
External genitalia normal and healthy
Palpation-
Tenderness present on the right hypochondriac region with no localised raise in temperature
Liver- tender, non pulsatile swelling palpated in the right hypochondium 2cm below the right coastal margin which moves with respiration and is firm in consistency. Smooth surface felt with rounded edges.
Spleen- non tender, unpalpable.
Kidneys-non tender and unpalpable.
No other palpable swellings
Percussion-
Resonant sound heard over the abdomen
No fluid thrills
Dull note of liver heard upto 2cm from the coastal margin
Auscultation- bowel sounds heard, normal aortic bruit heard, no venous hums or rubs
LOCAL EXAMINATION
Ulcer of 4x3 noted on the left gluteal region.
Abscess drained
Day 1
Day 2
Day 5
Day 3
Day 4
Provisional Diagnosis: Grade 2 fatty liver with hepatomegaly, cholelitheasis with gall bladder sludge. Fever secondary to gluteal abscess
Investigations:
*complete blood picture
Blood group B-ve
Haemoglobin 11.7
Total leukocyte count- 22,400
Red blood cell count- 3.8
Platelet count- 5 lakhs
Blood urea- 58
Serum creatinine-1.9
Serum sodium-127
Serum potassium-3.4
Serum calcium-92
Thyroid profile
T3- 0.33
T4-10.46
TSH-3.30
Complete urine examination
Clear urine
Acidic
Sugars absent
Pus cells- 3-6
Epithelial cells 2-4
Chest x ray
ECG
Abdominal usg
Treatment:
1.NBM till furthur order
2.INJ PIPTAZ 2.25gm IV/TID
3.INJ METROGYL 500mg IV/TID
4.IV FLUIDS 1unit NS, RL, DNS @ 100ml/hr
5.INJ PAN 40mg IV/OD
6.INJ ZOFER 4mg IV/SOS
7.INJ NEOMOL 1gm IV/SOS
8.TAB PCM 650mg PO/TID
9.T CINOD 10mg po/OD
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