1801006126 CASE PRESENTATION
Long case
A 50 year old male, resident of Miryalagudem who works in an ice factory came with
Chief complaints:
weakness of right upper and lower limbs since 7days
slurred speech since and deviation of mouth to left side 7days
History of presenting illness:
Patient was apparently asymptomatic 1 month back, then he developed giddiness and weakness followed by fall and was taken to local hospital when he was diagnosed to have hypertension and his condition improved with medication in about 3 days.
He took medication for 20 days and stopped for next 10 days
Then he developed sudden onset of weakness in right upper and lower limbs (which was 7 days ago) 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 was taken to local hospital and then was referred to our hospital next day.
There is no history of:
loss of consciousness, altered sensorium,
fever,headache,vomiting,seizures
No h/o tingling and numbness
No H/o diplopia, blurred vision, drooping of eyelids, able to chew food and no difficulty in swallowing
Past history:
He is a known case of hypertension since 1 month.
There is no history of diabetes, asthma,TB,epilepsy,coronary artery disease or thyroid abnormalities.
Personal history:
The patient wakes up at 4:00am in the morning daily. He has tea and goes to work in the ice factory. He lives very close to the ice factory.
He has breakfast at around 8 to 9 am(rice and curry). He then goes back to work and comes home for lunch at around 2:00 pm. He usually has rice with curry and dal for lunch.
Diet-Mixed ,He finishes work by around 6:00 pm, comes home, has tea and takes a bath. Sometimes he works until 9:00 pm. He sleeps by 9:00 pm.
The patient has history of chewing tobacco for around 10 years.
He consumes alcohol regulary since 30 years. He stopped for around 3 years and started again 6 months ago.
Bowel and bladder movements-regular.
Treatment history:
He took medication for hypertension- Amlodipine and Atenolol for 20 days and stopped for the past 15 days.
Family history:
No history of similar complaints in the family.
General examination:
Patient is conscious and cooperative.
He is well oriented to time,place and person.
Moderately built and nourished.
Vitals :-
Temp - afebrile
BP - 140/80 mm Hg
Pulse rate - 78 bpm
Respiratory rate - 14 cycles per minute
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Oedema - absent
SYSTEMIC EXAMINATION:
CNS EXAMINATION:
Right handed person.
Higher mental functions are intact.
Speech- slurred
Behaviour-normal
Memory- intact
Intelligence-normal
No hallucinations or delusions
Gait:walks with support
CRANIAL NERVE EXAMINATION:
I - no alteration in smell
II -
Visual acuity- normal
Field of vision- normal
Color vision - normal
III, IV, VI -
EOM- normal
Diplopia- absent
Nystagmus absent
No ptosis
V - sensations of face normal, can chew food normally
VII - Deviation of mouth to the left side, upper half of right side and left side normal
Taste sensation over anterior 2/3 of tongue present
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
Pupils - both are normal in size, reactive to light
Motor examination:
Tone:
RUL: increased
LUL: normal
RLL: increased
LLL: normal
Power:
RUL: 4/5
LUL: 5/5
RLL: 4/5
LLL: 5/5
Reflexes:
Superficial reflexes:
Right Left
Corneal : present present
Conjunctival: present present
Abdominal: present in all quadrants
Plantar : not elicited flexion
Deep tendon reflexes:
Right Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee jerk +++ ++
Ankle jerk +++ ++
Sensory examination:
Pain, temperature, crude touch, pressure sensations- normal
Fine touch, vibration, proprioception- normal
Tactile localisation- able to localise
No abnormal sensory symptoms
Cerebellar examination:
Finger nose test- normal
No dysdiadochokinesia
Knee heel test - normal
CVS EXAMINATION :-
JVP: Normal
INSPECTION:
Chest wall symmetrical
Pulsations not seen
PALPATION:
Apical impulse – normal
Pulsations – normal
Thrills absent
PERCUSSION:
No abnormal findings
AUSCULTATION:
S1, S2 heard
No murmurs
No added sounds
ABDOMINAL EXAMINATION :-
INSPECTION:
1. Shape – flat
2. Flanks – free
3. Umbilicus – Position-central, Shape-normal
4. Skin – normal
5. Hernial Orifices - normal
PALPATION:
Abdomen is soft and non tender
No hepatomegaly
No splenomegaly
Kidneys not enlarged, no renal angle tenderness
No other palpable swellings
Hernial orifices normal
PERCUSSION:
Fluid Thrill/Shifting dullness/Puddle’s sign absent
AUSCULTATION:
Bowel sounds – normal
No bruits, rub or venous hum
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.
1. Breath sounds - Normal Vesicular Breath sounds
2. Added sounds - absent
3. Vocal Resonance - normal
4. Bronchophony, Egophony, Whispering Pectoriloquy absent
PROVISIONAL DIAGNOSIS:
Acute Cerebrovascular accident with Right Hemiparesis due to involvement of internal capsule posterior limb
Investigations:
Blood sugar random - 109 mg/dl
FBS - 114 mg/dl
Hemoglobin- 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
T3 - 0.75 ng/ml
T4 - 8 mcg/dl
TSH - 2.18 mIU/ml
MRI:
Impression:
Acute infarct in posterior limb of left internal capsule
Old lacunar infarct in left side of pons
Few microhemorrhages in bilateral cerebral hemispheres.
Doppler:
USG:
No sonological abnormalities detected.
ECG:
FINAL DIAGNOSIS:
Cerebrovascular accident with Right sided hemiparesis ,
Acute infarct in posterior limb of internal capsule.
TREATMENT:-
Tab.ECOSPRIN
Tab.CLOPITAB 75mg PO/OD
Tab.Stamlo beta
Physiotherapy of right upper limb and lower limb
A 70year old came to the OPD with
Chief complaints of:
Bilateral pedal edema since 2months
Shortness of breath since 2 weeks
HOPI:
Patient was apparently asymptomatic 12days back then he developed bilateral pedal edema which was gradual in progression, extended upto knee and is of pitting type.
He also developed Shortness of breath which was initially grade 2 and progressed to grade 4(nyha)
Associated with orthopnea
H/o loss of appetite since one week and nausea three days back (3 episodes)
History of hypertension since 10years
No H/o- fever,burning micturation, diarrhoea
No H/o cough, hemoptysis,fever,
No h/o chest pain,giddiness , palpitations, decreased urine output, syncopal attacks,
No h/o abdominal distension, jaundice,vomitings
Past history:
Not a K/C/o Diabetes Mellitus,Asthma,TB,epilepsy,leprosy,CAD
Treatment history
Not significant
Personal history:
Diet:Mixed
Appetite:Decreased
Sleep-adequate
Bowel movements-regular
Bladder movements- normal urinary output
Addictions-chronic alcoholic since 30years and Tobacco smoking since 40years.
Family history: Not significant
General examination:
Patient is conscious,coherent,cooperative and well oriented with time,place,person
Poorly nourished and thin built
No signs of pallor,icterus,cyanosis,clubbing,
lymphadenopathy
Bilateral pedal edema is present pitting type .
Vitals:
Temperature: 98.4 degree Fahrenheit
BP-100/80mmHg
PR-104bpm
RR-21cpm
Grbs- 147mg/dl
Systemic examination:
Respiratory system:
Inspection-
Trachea-central
Chest appears b/L symmetrical and elliptical in shape
Palpation-
Trachea central in position
Measurements-
AP diameter-16cms
Transverse diameter-26cms
Tactile vocal
Fremitus Right Left
Supraclavicular N N
Infraclavicular N N
Mammary N N
Inframammary N N
Axillary N N
Infraaxillary Decreased bilaterally
Suprascapular N N
Infrascapular Decreased bilaterally
Percussion
Right Left
Supraclavicular R R
Infraclavicular R R
Mammary R R
Axillary D D
Suprascapular R R
Infrascapular D D
R-Resonant,D-Dull)
-Auscultation Right Left
Supraclavicular NVBS NVBS
Infraclavicular NVBS NVBS
Mammary NVBS NVBS
Inframammary NVBS NVBS
Axillary NVBS NVBS
Infraaxillary Crepitations heard
Suprascapular NVBS NVBS
Infrascapular Crepitations heard
NVBS-Normal vesicular breath sounds heard
CVS:
Inspection:
• Chest is bilaterally symmetrical.
•Trachea is central
•Movements are equal bilaterally
•. No parasternal haeve
•NO Visible epigastric pulsations
• No scars or sinuses
•Apical impulse seen in left 6th
intercostal space lateral to mid
clavicular line
Palpation:
•All inspectory findings are confirmed:
Trachea is central, movements equal bilaterally.
•Apex beat felt in left 6th intercostal space lateral
to midclavicular line
Para sternal heave not seen
Auscultation:
•S1 S2 heard
•No murmurs
Per abdomen:
•Scaphoid
•Visible epigastric pulsations
•No engorged
veins/scars/sinuses
•Soft , non tender
•No organomegaly
•Tympanic node heard all over
the abdomen
•Bowel sounds present
CNS:
•HMF - Intact
•Speech – Normal
•No Signs of Meningeal
irritation
•Motor and sensory system –
Normal
•Reflexes – Normal
•Cranial Nerves – Intact
•Gait – Normal
•Cerebellum – Normal
•GCS Score – 15/15
Provisional diagnosis:
Comgestive cardiac failure with bilateral pleural effusion
Investigation:
Chest X-Ray:
Hemogram:
Hemoglobin-9.3gm/dl
Total count-12,800 cells/m3
Neutrophils-95%
Lymphocytes-62%
Eosinophils-0%
PCV-29.7 vol%
RDW-14.2%
USG:
Bilateral moderate pleural effusion with collapse of underlying lobes.
ECG -
Blood sugar-80mg/d
Serum creatinine:1.4gm/dl
Blood urea - 21 mg/dl
FINAL DIAGNOSIS-
heart failure with pleural effusion
Treatment
*Injection lasix 40 mg iv BD
* TAB Nicardia 10 mg po BD
* TAB DYTOR 20mg po.BD
*Vitals monitoring 6th hourly.
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