1801006134 CASE PRESENTATION
long case
This is a case of a 50 year old male, resident of Miryalguda, factory worker by occupation, presented with
CHEIF COMPLAINTS-
Weakness of right upper and lower limbs with and deviation of mouth to the left since 3 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month ago, then he developed giddiness and weakness of left upper and left lower limb which was sudden in onset followed by fall. He was then taken to the hospital where he was treated for the same and diagnosed with hypertension. His symptoms resolved in around 3 days. The patient was compliant with his hypertension medication for 20 days and stopped taking it after that.
The patient then developed weakness of right upper limb and lower limb 3 days ago which was sudden in onset. He noticed the weakness on his right side when he woke up in the morning. He felt unsteady as he stood up after waking up.
The weakness of right side was also associated\ and deviation of the mouth to his left side. He was taken to a hospital nearby where he underwent a CT scan. He was then referred to our hospital the next day.
There is no history of difficulty in swallowing, behavioural abnormalities, fainting, sensory disturbances, fever, neck stiffness, altered sensorium, headache, vomiting, seizures, abnormal movements, falls.
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 month .
Not a k/c/o Diabetes,asthma, coronary artery diseases,epilepsy,thyroid disorders.
FAMILY HISTORY:
No similar complaints in the family
PERSONEL HISTORY:
( daily routine )
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 comes home and has breakfast at around 8 to 9 am. He usually has rice and curry for breakfast. 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. He consumes chicken or mutton thrice weekly. He sometimes takes a nap in the afternoon depending on his work for the day. He finishes work by around 6:00 pm following which he comes home, has tea and takes a bath. Sometimes he works until 9:00 pm. He sleeps by 9:00 pm.
The patient has been chewing tobacco for around 10 years. 1 packet of tobacco lasts for 2 days.
He consumes alcohol on a regular basis since 30 years. He stopped for around 3 years and started again 6 months ago.
Bowel and bladder movements are regular.
TREATMENT HISTORY:
He is on antihypertensives (amlodipine and atenolol) since 1month 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.
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Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Oedema - absent
Vitals :-
Temp - afebrile
BP - 145/80 mm Hg
Pulse rate - 78 bpm
Respiratory rate - 14 cycles per minute
SYSTEMIC EXAMINATION:
CNS EXAMINATION:
Dominance - Right handed
Higher mental functions
• conscious
• oriented to time,person and place
• memory - immediate,recent,remote intact
•slurring of speech
GCS( Glasgow coma scale)
Cranial nerves -
CN1:
Sence of Smell - Normal
2. CN2:
visual acuity - NORMAL
3. 3,4,6 CN
EOM movement - normal
5 CNMotor - masseter, Temporalis, - N, N
Reflexes - Corneal
7 CN
Motor
Occipito frontalis - equal on both sides
Orbicularis oculi - equal onboth sides
Deviation of mouth to the left side, upper half of left side and right side normal
8 CN - hearing is normal, no vertigo or nystagmus
9,10CN- no difficulty in swallowing
11CN- neck can move in all directions
12CN - tongue movements normal, no deviation
Power:-
Rt UL - 3/5 Lt UL-5/5
Rt LL - 3/5 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: Muted Flexion
Involuntary movements - absent
Fasciculations - absent
Sensory system -
-Pain, temperature, crude touch, pressure sensations normal
-Fine touch, vibration, proprioception normal
-two point discrimination -able to discriminate and tactile localisation -able to localise
Cerebellum -
Finger nose test normal, no dysdiadochokinesia, Rhomberg test could not be done
Autonomous nervous system - 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.
RESPIRATORY EXAMINATION :-
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:
Acute Cerebrovascular accident with Right Hemiparesis due to involvement of internal capsule posterior limb
INVESTIGATIONS
Anti HCV antibodies rapid - non reactive
HIV 1/2 rapid test - non reactive
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
X-RAY
ECG
MRI scan
CONFIRMED DIAGNOSIS:
Cerebrovascular accident with Right sided hemiparesis ,
Acute infarct in posterior limb of internal capsule.
TREATMENT:
Inj. OPTINEURON in NS 100 ml
Tab. ECOSPRIN
Tab. CLOPITAB
Tab. ATOROVASTAT
Tab. STAMLO BETA
Physiotherapy is advised
With chief complaints of
Sob since 2days
feverr since 1 week,,
Pain and swelling in the perianal region since 10 days
HOPI:
The patient was apparently asymptomatic 9 years ago
Course of events:
9 years ago:
She had polyuria,polydipsia,polyphagia weakness and weight loss due to which she visited a local hospital and there her grbs was high and was diagnosed to be having diabetes and started on insulin injection and was using since then?
Inj mixtard 20U - x- 15U.
In between due to raised sugar levels she develops abdominal pain and consults a doctor and takes fluids and high dose of insulin
1 week ago:
Patient had swelling over Analverge a which was initially 1x 1cns and progressed to the present size of 4x4 cms associated with discharge of pus and mixed with blood, associated with High grade fever associated with chills and rigor for which she consulted local doctor and prescribed antibiotics and she used for 5 days and also developed nausea due to which she was not on proper diet and so she decreased her insulin dosage to 5u - 5u on her own since 3 days and developed sob on rest since 2 days and yesterday as sob was increased and got her Grbs checked at home and it was 480mg/dl and was taken to local hospital and was given injection ( not known)and since today morning her sob was increased went to hospital and RBS being high insulin14u HAI given and referred here for further management
Past history:
H/O similar complaints of swelling in inner thighs and in gluteal region 1 year back as she has taken covid vaccine on that time and she consulted local doctor and recieved antibiotics ( amoxiclav 625mg/po/bd for 5 days and also herbal medicine for swelling local application it got relieved
Not a k/c/o hypertension, Tb,asthma, epilepsy, thyroid disorders
Menstrual history:
Age of menarche: 13 years
Menses: regular,28 days cycle
Flowincreased associated with clots and pain
Personal history:
Appetite: decreased
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
Addictions: no
Family History:
her father is a known case of diabetes since 16 years and he was using insulin mixtard 2 times daily
General examination:
Patient was conscious, coherent, cooperative.
Pallor: present
Icterus: absent
No cyanosis, clubbing, lymphadenopathy,edema
Vitals:
Temperature: 101 F
Bp: 123/70mmhg
PR: 92 BPM
RR: Tachyponeic at the time of admission
21cpm
Spo2: 98% on ra
Grbs:
Surgery referral notes:
On local examination:
Inspection:
Swelling was in perianal region which was initially 1x1 cms and progressed to present size of 4x4 cms
Pus discharge present
Skin over swelling: reddish colour
Palpation:
Tenderness+
Local rise of temperature
Induration of skin over the swelling+
Visible pus discharge
Pictures captured by Dr lohith pgy1
Incision and drainage of pus was done under spinal anaesthesia
After iand d of abscess picture:
On6/1/23:
On 7/1/23:
Systemic examination:
Respiratory system:
Inspection:
Position of trachea; midline
BAE-PRESENT,
Per abdomen:
Inspection
CVS:
Inspection;
CNS:
Higher mental functions intact
ECG:
Chest x ray:
2d echo:
No AR /MR/TR
No RWMA,No As/ps
Good lv systolic function
No diastolic dysfunction
Diagnosis:
Diabetic ketoacidosis with Type 1 DM since 6 years with perianal abscess.
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