1801006144 CASE PRESENTATION
long case
CHEIF COMPLAINTS :-
A 79 year old male was brought to the OPD with cheif complaints of cough since 20 days ,C/o altered sensorium since 3 days, difficulty in swallowing since 1 month and fever since 10 days
HISTORY OF PRESENTING ILLNESS :-
Patient was apparently asymptomatic 20days back then he developed cough which was insidious in onset and gradually progressive. The cough was productive but patient was not able to spit it out and he also faced Difficulty in swallowing.
20 days back ( on feb 25th) he started to have cough and cold
On march 1st took treatment for cold
On march 3rd secretions got increased and he was unable to spit that out
After 2 days went to a hospital and got admitted for 5 days during which he got those secretions cleared out
H/o change of voice since 20 days, insidious, hoarse in character and
Slurring of speech was seen.
H/o cough on intake of liquids.
No h/o hemoptysis, difficulty in breathing, breathlessness.
High grade Fever was since 10 days associated with Chills and rigors
There is no history of vomiting, chest pain, loose stools.
events history:-
-> 10 years back , patient developed lesions on his both foot and out of no where and went to the doctor and found to have diabetes and was put on medication and after 1 year with regular check up he was diagnosed Hypertension and was put on antihypertensive medication.
-> 7 years back, patient developed head ache at morning, shoulder ache at evening and become sick by night followed by vomtings he was taken to hospital and was thought to have a heart problem and sent back home, but on that night itself he developed leg pain and itching
Patient was awake on that night due to left hand weakness and itching
-> On NEXT DAY Morning they took him to hospital And the Patient was able to lift his hand But was unable to hold objects.
-> AFTER 3 DAYS patient developed left sided hemiplegia.
For which he was admitted in hospital
He took liquid deit for 3 months because the patient was unable to eat solid foods and then he slowly started eating solid foods
-> One year back [2022]
He got seizures for 5min and they took him to the hospital.
From 7 years onwards , patient was bedridden with foleys attached to him and physiotherapy was done by his attenders daily, but there no improvement was seen
20 days back, from March 1st onwards patient developed slurring of speech, mild cough unable to clear the throat secretions and decreased responsiveness and was taken to the hospital and was treated with antibiotics and patient was brought here for further evaluation.
PAST HISTORY :-
K/c/o CVA with left hemiplegia since 7 years.
K/c/o seizures disorder since 2 years
K/c/o hypothyroidism since 5 years
PERSONAL HISTORY :-
Appetite - decreased
diet - mixed
Bowel- constipation present
Bladder - regular
No known allergies and Addictions
Family History- not significant
GENERAL EXAMINATION :-
PATIENT is unconscious incoherent
pallor: PRESENT
no pedal edema, icterus, cyanosis, clubbing, lymphadenopathy
VITALS ON ADMISSION :-
PR-90 BPM
BP- 140/80MM HG
RR- 22 CPM
SPO2- 98% AT RA
GRBS - 183mg/dl
SYSTEMIC EXAMINATION :-
Respiratory :-
Inspection : respiratory movements equal on both sides
Trachea central
palpation : apical impulse in left 5th intercostal space
Auscultation : normal vesicular breath sounds
Percussion- BAE+
CNS
PATIENT is unconscious incoherent uncooperative
HIGHER MENTAL FUNCTIONS- cannot be elecited
Speech
Behaviour
Memory
Intelligence
Lobar functions
CRANIAL N. EXAMINCTION :-
1. CN
Sence of Smell - cannot be elecited
2. CN
visual acuity - cannot be elecited
Corneal reflexe present
3,4,6 CN
EOM movement - cannot be elecited
Pupil size - 2, 3 mm
Direct and indirect light reflex - present, present
Ptosis - absent, absent
Nystagmus - absent, absent
5 CN
cannot be elecited
Sensory over face & buccal mucosa -
Motor - masseter, Temporalis, pterigoids -
Corneal reflux present
Jaw jerk-
7 CN
Motor
Nasolabial fold - absent on right side
Occipito frontalis - cannot be performed
Orbicularis oculi - cannot be performed
Orbicular oris - cannot be performed
Buccinator - equal om both sides
Sensory:
Taste over anterior two third of tongue - ppt is not consciousness to perform
8 CN - cannot be elicited
Rinnes test
Webers test
9, 10 CN - cannot be elicited
Uvula palatal arches movements -
Gag reflex - intact
palatal reflex -
11 CN - could not be elicited
Trapezius
Sternocleidomastoid
12 CN
wasting - present
Fasciculations - no
Tongue protrusion to midline -can be elicited
MOTOR SYSTEM EXAMINATION :- could not be elicited
Power - cant be elicited
U/L
Shoulder -
Flexion - Extention
lateral - medial rotation
Abduction -Adduction
Elbows -
Flexion - Extension
Wrist -
DorsiFlexion - palmar flexitar
Adduction - Abduction
Pronation - Supination
Hand grip
L/L ->
Hip
Flexion- Extension
lateral rotation - Medial rotation
Abduction - Adduction.
Knees -
Flexion - extention
Ankle -
DorsiFlexion - plantar flexion
Inversion - eversion.
Trunk muscles - rolling over bed cannot be elicited
Superficial reflexes -
Corneal - N, N
Abdominal - N, N
Plantar response-
Deep Tendon reflexes -
Biceps
Triceps -
Knee -
Ankle -
https://youtube.com/shorts/bAwnwz6TUfM?feature=share
Cerebellar examination - could not be elicited
Finger Nose test
Finger finger test
Dysdiadokinesia
Heel knee test
Tandem walking
Rhombergs test
SIGNS OF MENINGEAL IRRITATION: absent
Sensory System examination - could not be performed
Spinothalamic tract
Crude touch
Pain
Temperature
Posterior Column
fine touch
Vibration
position sense
Cortical -
Two point discrimination
Tactile localization
Graphesthesia
Stereognosis
Gait could not be done
Examination of spine - normal
CVS :-
Auscultation: s1s2 +,no murmurs
P/A :-
inspection: umbilicus is central and inverted, all quadrants moving equally with respiration,no scars,sinuses, engorged veins, pulsations
auscultation: no bowel sounds heard
bed sores
C/o asymptomatic lesions all over the body since 2 months
H/o application of unknown topical medications used
On examination, multiple hyperpigmented lesions were seen all over the body with scaly lesions over the upper back
Diffuse xerosis present
single ulcer of size 1.5x1.5 cm over the back.
Diagnosis - Senile Xerosis with post inflammatory hyperpigmentation
A pressure ulcer was also seen at base of scrotum
INVESTIGATIONS :-
HbsAg rapid - negative
Xray -
Blood urea -30mg/dl
HBA1C-6.7%
HIV 1/2 RAPID TEST - NON REACTIVE
Anti HCV antibodies rapid - nonreactive
TOTAL BILIRUBIN -0.81mg/dl(normal-0 to 1mg/dl)
Direct bilirubin-0.17mg/dl(0 to 0.2mg /dl)
Serum creatinine -0.9 mg/dl (0.8 to 1.3 mg /dl)
Electrolytes -
Sodium 135meq/l
Potassium 3.5 meq/l
Chloride 98meq/l
Calcium -1.06 mmol/l
ABG -
Ph 7.51
PCO2 29.5mmhg
Po2 67.5 mmhg
PROVISIONAL DIAGNOSIS:-
Left side hemiplagia associated with right side facial palsy involving right middle cerebral artery and lesion is in right internal capsule
TREATMENT
1) TAB ECOSPRIN 150 mg RT/OD
2) TAB CLOPIDOGREL 75 MG RT/OD
3) TAB ATORVAS 20 MG RT/OD
4) NEBULISATION - 3% NS
5)CHEST PHYSIOTHERAPY.
6) RT FEEDS 100 ML WATER 2nd HRLY
50 ML Milk 2nd HRLY.
7) TAB. LEVIPIL
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SHORT CASE
38 yr male with abdominal pain
CHIEF COMPLAINTS
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 5 years ago then he developed pain in upper abdomen which is insidious in onset and gradually progressive,dragging type of pain radiating to back of thorax. Initially the pain used to be once in every 6 months but from 6 months the pain occurs once or twice in every month associated with vomiting. Aggravated on taking heavy food and alcohol and relieved temporarily on medication
On 13th February he had 5 to 6 episodes of vomiting after having food or water. Initially vomitus contain undigested food particals later it contain thick Yellow color fluid. Vomiting was associated with weakness. He was treated temporarily in local hospital.
On 1 march he had another episode of pain..temporarily he got treated in local hospital and on 15th he was admitted in our hospital.
PAST HISTORY
No h/o Dm,htn,tuberculosis,epilepsy,asthma,cvd
5 years ago he had abdominal pain and he was diagnosed as pancreatitis. He was on medication pantoprezole, pancreatic,citrex for 3 months symptoms relieved for next 3 months after stopping medication and another episode of abdominal pain followed by medication for next 3 months...
Since 6 months he is having abdominal pain associated with vomiting weakness
PERSONAL HISTORY
Addictions
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
PATIENT IS CONSCIOUS COHORENT COOPERATIVE. WELL ORIENTED TO TIME PLACE AND PERSON
MODERATELY BUILT AND MODERATELY NOURISH
NO SIGNS OF PALLOR, ICTERUS, CLUBBING, CYANOSIS, GENERALIZED LYMPHADENOPATHY, EDEMA
VITALS
Systemic examination
CVS
RS
CNS
P/A
Inspection
Palpation
Percussion
Auscultation
Investigations
Serum amylase 175 (normal 25 to 140IU/L)
Serum lipase 72 ( normal 13 to 60 IU/L)
Fasting Blood sugar 95 (normal 70 to 110mg/dl)
Liver function test
Ct
https://youtu.be/9Y8v7uLEMio
https://youtu.be/5Gd1eEkNnrc
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Provisional diagnosis
treatment
T.ULTRACET 1/2 TABLET
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