1801006118 CASE PRESENTATION
Long Case
A 50 year old male, resident of Miryalagudem , ice factory worker by occupation presented with the chief complaints of
Weakness in the right upper and lower limbs since 7 days
slurring of speech and deviation of mouth to the left since 7 days
HISTORY OF PRESENT ILLNESS:-
Patient was apparently asymptomatic 1 month back later developed giddiness and weakness of right upper and lower limbs followed by fall and diagnosed with hypertension during hospital admission.
Patient then developed sudden onset of weakness in the right upper and lower limb while going to washroom and he was swaying towards right side and unable to walk, associated with deviation of mouth towards left side and slurring of speech after few minutes and taken to the local hospital then referred to our hospital on next day morning.
Upper limb- Patient has difficulty in combing hair, difficulty in buttoning and unbuttoning
Lower limb- not able to stand due to swaying towards right side
No H/o difficulty in lifting the neck, rolling over the bed and no difficulty in breathing
No h/o tingling and numbness, patient is able to feel his clothes.
No H/o loss of consciousness, altered sensorium and headache, seizures and bowel and bladder disturbances
No complaints of memory or sleep disturbances and delusions
No H/o diplopia, blurred vision, drooping of eyelids, able to chew food and no difficulty in swallowing
Patient has no difficulty in closing eyes , lips, able to sense taste and able to move neck and tongue
No H/o fever, vomiting, headache , neck stiffness or any trauma to the head.
PAST HISTORY:-
Known case of hypertension since 1 month
Patient started using medication for hypertension for 20days and stopped for next 10days.
Not a known case of diabetes, asthma, tuberculosis, epilepsy, thyroid abnormalities,coronary artery disease.
PERSONAL HISTORY:-
Daily routine:
Wakes 4am in the morning and stays close to his workplace, breakfast around 8-9am, lunch around 2pm usually takes rice and curry in his meals and consumes chicken/mutton twice weekly. He comes home by 6pm evening and sleeps by 9pm
Diet - mixed
Appetite- normal
Bowel and bladder movements - regular
Adequate sleep
Patient consumes alcohol since last 20years and chewing tobacco since last 10years.
1 packet for 2days
DRUG HISTORY:-
Takes medication for hypertension- Atenolol and amlodipine for 20days after diagnosed with hypertension and stopped for next 10days.
FAMILY HISTORY:-
No similar complaints in family
GENERAL EXAMINATION:-
Patient was conscious, coherent, cooperative, well oriented to time, place and person.
Moderately built and well nourished.
Vitals-
BP : 140/90mm Hg
Pulse rate : 74bpm, normal volume, regular
Respiratory rate : 15cpm
Temp : Afebrile to touch
No pallor , icterus, cyanosis, clubbing, lymphadenopathy, edema.
No neurocutaneous markers
SYSTEMIC EXAMINATION:-
CNS EXAMINATION:-
Higher mental functions intact- conscious, oriented to time place and person
Speech - no aphasia , dysphonia, dysarthria
Fluency, repetitions, naming - intact
No delusions and hallucinations
No signs of meningeal irritation
GCS scale - 15/15
Gait - walks with support
Cranial nerves:-
1 no alternation in smell
2 visual activity normal
3,4,6 - eye movements in all directions
5 - normal sensations on face , mastication- normal, corneal reflex - normal
7 - deviation of mouth towards left side
8 - no hearing impairment, vertigo and nystagmus absent
9,10 - no difficulty in swallowing , no deviation of uvula, gag reflex +
11 - normal neck movements
12 - tongue movements normal, no deviation of tongue
Pupils - normal in size , reactive to light
Motor system
Bulk
TONE :
Rt Lt
UL Increased N
LL Increased N
POWER:-
Rt Lt
UL 4/5 5/5
LL 4/5 5/5
REFLEXES:
Rt Lt
Biceps +++ ++
triceps +++ ++
supinator ++ ++
knee +++ ++
ankle +++ ++
plantar extension flexion
Gait - not able to walk properly , need support while walking
Involuntary movements - absent
Fasciculation - 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, no intentional tremor, Romberg test could not be done
Spine and cranium - no deformities
CVS EXAMINATION :-
JVP: Normal
INSPECTION:
Chest wall symmetrical
Trachea central
PALPATION:
Apical impulse felt
Thrills absent
PERCUSSION:
No abnormal findings
AUSCULTATION:
S1, S2 heard
No murmurs
ABDOMINAL EXAMINATION :-
INSPECTION:
Flat shaped, free flanks , umbilicus central and normal in shape, hernial orifices normal
PALPATION:
Abdomen is soft and non tender, no hepatomegaly, no splenomegaly
Kidneys not enlarged, no renal angle tenderness
PERCUSSION:
Fluid Thrill/Shifting dullness/Puddle’s sign absent
AUSCULTATION:
Bowel sounds – normal
No bruits
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.
Normal Vesicular Breath sounds heard.
Norm vocal resonance.
Vocal Resonance - normal
PROVISIONAL DIAGNOSIS:-
Acute Cerebrovascular accident ,mostly infarct in left internal capsule involving left MCA territory
INVESTIGATIONS:
Anti HCV antibodies rapid - non reactive
HIV 1/2 rapid test - non reactive
Blood sugar random - 109 mg/dl
FBS - 114 mg/dl
Haemoglobin- 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
USG:-
TREATMENT:-
1. INJ. OPTINEURON 1 AMP IN 100ML NS IV/OD
2. TAB. ECOSPRIN AV 75/10 PO/HS
3. TAB. CLOPITAB 75 MG PO/OD
4. PHYSIOTHERAPY OF RIGHT UPPER AND LOWER LIMB
5. SYRUP. CREMAFFIN PLUS 15ML PO/HS
A 38yr old male resident of West Bengal , civil engineer by occupation came to the OPD with chief complaints of abdominal pain since 5 years
HOPI :-
Patient was apparently asymptomatic 5 years back then developed pain abdomen which is sudden in onset , gradual in progression , dragging type radiating to back which aggravates on intake of food, alcohol and relieved on medication.
For the past 1 year patient has episodes of vomiting followed by pain in abdomen at least once in 2 months which is non bilious and water as content associated with weakness and giddiness
On13th November he had multiple episodes of vomiting after lunch, initially vomiting containing food particles (yellowish) later watery associated with weakness and giddiness and not relieved on medication.
On 23rd November he had similar episode of pain and took medication
He also complains of severe weight loss.He was 86 kgs 6 months ago but at present he reduced to 67 kgs.
H/o accident 1 year ago, injured at elbow and knee, dental injury
Patient also complains of constipation and per rectal bleeding since childhood.
Daily routine: He wakes up at 6am in the morning , have breakfast ,go to the office ,completes his work and returns by 5pm and plays badminton or football and then comes to home ,have dinner at 8pm and goes to bed by 10pm
Past history:-
Known case of haemorrhoids since 12 years of age
History of jaundice when he was 12 years old which later subsided
History of trauma to the nose while playing football during childhood (15 years) and developed Deviated nasal septum towards left side.
H/o Appendicectomy when he was 17 years old
H/o leprosy 12 years ago
N/K/C/O DM, Hypertension,TB, Asthma, epilepsy
H/o psychiatric problem- depression, insomnia which not subsided on medication
Family History:-
Not Significant
Personal History:-
Diet - Mixed
Appetite - Normal.
Sleep - Inadequate
B&B - Bowel - constipation since 12 years old
Bladder movements normal
Addictions - Alcohol - 180mL to 375mL everyday from 10 years. From last 6months he decreased consuming alcohol
Smoking - Initially 2 packs per day back when he was in college later 1 pack per day
Allergic History :-
Not allergic to any food or drug
Treatment History:-
Anti anxiety drugs
Medications to induce sleep- atiavin 2mg
Ayurvedic medicine( Jandu?) for constipation
Pancreotid, pantocid dsr, creotox previously
Tramadol for pain
GENERAL EXAMINATION -
Patient was conscious, coherent, cooperative and well oriented to time, place and person
Moderately built and nourished
Pallor , icterus , cyanosis , clubbing , lymphadenopathy , edema - ABSENT
Temperature 94F
PR :- 80bpm
RR :- 16cpm
BP :- 110/70 mmHg
SpO2 :- 98%
SYSTEMIC EXAMINATION:-
CVS - S1 , S2 heard, No murmurs
RS - B/L airway entry + , Normal vesicular breath sounds - heard
CNS - No focal and neurological deficits
P/A
Inspection: Not distended , umblicus inverted , No discharging sinus seen, Scar in the RIF ( Appendicectomy)
Palpitation : No local rise in temperature, Mild tenderness in epigastric region, No organomegaly
Percussion: tympanic
Auscultation: Bowel sounds audible
BURSA can be felt on palpitation at elbow and hip areas
PROVISIONAL DIAGNOSIS : pancreatitis
INVESTIGATIONS:-
CBP
HB 11.2 gm/dl
total count 4700 cells/Cumm
Neutrophil 64%
Lymphocytes. 22%
Monocytes. 2%
Basophils 1%
Smear normocytic normochromic
Liver functional test
Total Bilirubin 1.53mg/dl
AST 42 IU/L
ALT 72 IU/L
ALP 1243 IU/L
Total proteins 5.3gm/dl
Albumin 2.98GM/DL
Serum lipase 72IU/L
Serum amylase 176 IU/L
CT ABDOMEN:-
USG Right elbow-
Features of mild Right Olecranon bursitis
TREATMENT:
1.T.ULTRACET
2.BP MONITORING
3.VITALS MONITORING 6TH HRLY
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