1801006148 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 slurring of speech 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(lower limb>upper limb) 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 with slurring of speech 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.

PAST HISTORY:

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.

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - absent 

Vitals :- 

Temp - afebrile

BP - 140/80 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

Cranial nerves - 

I - no alteration in smell

II - no visual disturbances

III, IV, VI - eyes move in all directions

V - sensations of face normal, can chew food normally 

VII - Deviation of mouth to the left side, upper half of left side and right side normal

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

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

ECG

CT scan

MRI scan

CONFIRMED DIAGNOSIS:

Left sides 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

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short case

CHEIF COMPLAINTS:

Difficulty in breathing,pedal edema and generalised weakness since 20 days

HISTORY OF PRESENT ILLNESS:

Pt was apparently asymptomatic 3 months back, then developed Difficulty of breathing which was insidious in onset and gradually progressed from grade 2 to 3. This was associated with pedal edema and not associated with chest pain or palpitations. 

Orthopnea (+)ve, PND (+)

Not h/o facial puffiness, no decreased urine output, no burning micturition

H/o fever on and off since 2 months

PAST HISTORY:

Pt was diagnosed with dengue 1 month prior

K/c/o DM since 10 years, on T. Zoryl-m2 po/bd

K/C/O serizure disorder, on T. Carbamazepine 200mg po/od

Not k/c/o HTN, CAD, asthma, CVA, TB

No h/o blood loss, past surgeries, hemorrhoids, hemoptysis, hematuria or Malena

PERSONAL HISTORY:

Sleep adequate, appetite decreased, bowel movements decreased, bladder regular, occasional alcoholic, non smoker

GENERAL EXAMINATION:

O/e- pt is conscious, coherent, cooperative with respect to place ,time and person , moderately built and nourished 

AFEBRILE

BP- 150/80mmgHg

PR- 81 BPM

RR-24cpm

SPO2- 99% 

Severe pallor 

Pedal edema (+), b/l upto knees, pitting type

Clubbing (-)

SYSTEMIC EXAMINATION:

CVS EXAMINATION:

JVP: Normal

INSPECTION:

Chest wall symmetrical

Pulsations not seen

 PALPATION:

APEX BEAT AT 5th ICS , MCL

Thrills absent

PERCUSSION:

No abnormal findings

 AUSCULTATION: 

S1, S2 heard

No murmurs 

No added sounds

RESPIRATORY SYSTEM:

normal bilateral vesicular breath sounds

CNS: 

No neurological deficits

GIT:

No tenderness 

PROVISIONAL DIAGNOSIS

Heart failure 2° severe anemia 

INVESTIGATIONS:

Complete blood picture:

Hb:7.3 

TLC : 9900

PCV:22.8

MCV:65.7

MCH:21

MCHC:32

RDW CV:21

RDW SD:50

Platelet:3.59

RBC:3.47

Reti:0.7

RBS:70mg/dl

Sr. Cre:1.2

Pot:3.1

Sr.fe:80

Stool for occult blood : positive

Hba1c:6.5

Lipid profile:

Total cholesterol:146

Triglycerides:173

Hdl:30

Ldl:90

Vldl:34.6

2d echo :

Global hypokinesia with calcified and thickened aortic valve

Chest x ray :

ECG:

CONFIRMED DIAGNOSIS:

Heart failure Secondary to anemia 

TREATMENT:

Salt restriction < 2.4g/day

TAB LASIX 20mg PO/BD (if SBP > 110mm 0.8Hg)

TAB ZORY - M2 PO/BD

TAB ECOSPRIRIN - AV (70/20) PO/HS

TAB CARBAMAZEPINE 200mg PO/OD

BP-MONITORING 4th HRly

GRBS 6th HRly