1801006157 CASE PRESENTATION
long case
CASE:
A 50 year old male resident of miryalaguda, ice factory worker by occupation came with chief complaints of
Weakness of right upper and lower limbs since 5 days
Slurring of mouth since 5 days
Deviation of mouth since 5 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month back when he developed weakness and giddiness of right upper and lower limbs followed by fall and was diagnosed with hypertension during the routine checkup and advised to take medication for the same.
Patient then developed sudden onset of weakness in the right upper and lower limb 5 days back sudden in onset observed in the morning while he was 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 nearby hospital and where he underwent CT SCAN,then referred to our hospital the next day.
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 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 H/o diplopia, blurred vision, drooping of eyelids, able to chew food and no difficulty in swallowing
no history of 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:
30 years ago sustained a fracture in the right elbow.
Known case of hypertension since 1 month
Patient started using medication for hypertension for 20days and stopped for next 10days.
No history of diabetes mellitus, asthma, tuberculosis, epilepsy, thyroid abnormalities,coronary artery disease.
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 comes home and has breakfast at around 8 to 9 am. He usually takes 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 his work by around 6:00 pm following which he comes home, takes tea and bath. Sometimes he works till 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 after the death of his daughter’s husband.
Bowel and bladder movements are regular.
TREATMENT HISTORY:-
He consumed medication for hypertension Amlodipine and Atenolol for 20 days which he stopped around 10 days ago.
FAMILY HISTORY:-
No similar complaints in the family.
GENERAL EXAMINATION:-
Patient is conscious, cooperative, with slurred speech
Well oriented to time, place and person
Moderately built and moderately nourished.
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
Vitals :-
Temp - afebrile
BP - 140/80 mm Hg
Pulse rate - 75 bpm
Respiratory rate - 16 cycles per minute
SYSTEMIC EXAMINATION:-
1) CNS EXAMINATION:-
RIGHT SIDED DOMINANT
Higher mental functions intact-conscious,coherent,oriented to time place and person.
speech-no aphasia,dysphonia,dysarthria.
Memory- normal
No meningeal signs
No delusions and hallucinations.
Glasgow scale - 15/15
Gait - walks with support
Cranial nerves -
I - no alteration in smell
II - no visual disturbances
III, IV, VI - eyes move in all directions
V - sensations of face are intact,tone of muscles of mastication are normal.
VII - Deviation of mouth to the left side, upper half of right side and left side normal
VIII - hearing is normal,no vertigo and nystagmus.
IX,X - no difficulty in swallowing
XI - neck moves in all directions
XII - tongue movements normal, no deviation
Pupils - both are normal in size, reactive to light
Motor system:
TONE :
Rt Lt
UL Increased Normal
LL Increased Normal
POWER:-
Rt Lt
UL 4/5 5/5
LL 4/5 5/5
REFLEXES:
Rt Lt
Biceps +++ ++
triceps +++ ++
supinator +++ ++
knee +++ ++
ankle +++ ++
plantar extension flexion
.jpeg)
A 30 year old female completed her degree final year came with complaints of fever since 2 month’s and cough with sputum since 15 days.
HISTORY OF PRESENT ILLNESS:-
Patient was apparantly assymptomatic 2 months back and then she developed fever which was insidious in onset,high grade and not associated with chills and rigors and relieved on taking medication and again after one week she again developed fever which is of high grade and 15days back patient developed cough associated with sputum.And her sputum is scanty in amount,white in colour,no blood in sputum and non foul smelling sputum.And patient developed shortness of breath which is present only at nights not disturbing her sleep and she had known about it after her attenders noticed it.SOB at nights only since15 days which is on and off and 15days back diagonosed to be having pericardial effusion.
No loss of Apetite,No weight loss in last 2 months.
Not a known case of DM,HTN ,TB, ASTHMA, CAD and CVA.
Attendend a weight loss programme for which she lost 7kgs in last 7 mnths.
Her weight is now 66kgs.
PAST HISTORY:
No history of Hypertension,Diabetes mellitus, Asthma, Epilepsy, Tuberculosis,Coronary Artery disease.
PERSONAL HISTORY:
Diet: Mixed(eats meat once in a week)
Appetite: normal
Sleep: adequate
Bowel and bladder movements: normal
No addictions
No allergy
TREATMENT HISTORY:-
No significant treatment history
FAMILY HISTORY:-
No significant family history
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative
Well oriented to time, place and person.
No pallor,Icterus,Cyanosis,Clubbing,Koilonychia,
Lymphadenopathy and edema.
VITALS:-
Temperature:Afebrile
Blood pressure:130/80mmHg in right arm in sitting posture
Pulse Rate:120bpm,regular rhythm,normal volume
Respiratory Rate:18 cycles per minute
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Examined under adequate light
INSPECTION:
Shape of chest is elliptical
Chest is symmetrical in position
Trachea is central
No scars,sinuses,engorged vein
Palpation:
All inspectory findings are confirmed
No local rise of temperature
no tenderness
Chest expands more on the left side when compared to the right side
Percussion:
Stony dull sound on percussion in right infrascapular and right infraaxillary.
Auscultation:
Right infrascapular wheeze and right infraaxillary wheeze and left Infrascapular crepts are present.
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
PERCUSSION:
Fluid Thrill/Shifting dullness/Puddle’s sign absent
AUSCULTATION:
Bowel sounds – normal
No bruits
CVS:
INSPECTION:
Chest wall symmetrical
Trachea central
PALPATION:
Apical impulse felt
Thrills absent
PERCUSSION:
No abnormal findings
AUSCULTATION:
S1, S2 heard
No murmurs
CNS:
No focal neurological deficits
INVESTIGATIONS:-
Mantoux test:Done outside shows positive reaction.
CB NAAT of sputum:Shows negative for AFB
CHEST X-RAY:-
PROVISIONAL DIAGNOSIS:
pleural effusion secondary to TB.
Renal Function Tests:
Urea-19 mg/dL
Creatinine-0.7 mg/dL
Uric acid-3.0 mg/dL
Calcium -10.1 mg/dL
Phosphorous-4.1 g/dL
Sodium-134 mEq/L
Potassium-3.8 mEq/L
Chloride-100 mEq/L
Liver Function Tests:
Total Bilurubin-# 1 20 mg/dL
Direct Bilurubin-# 0 31 mg/dL
SGOT(AST)-# 45 IU/L
SGPT(ALT)-27 IU/L
ALKALINE PHOSPHATE-# 198 IU/L
TOTAL PROTEINS -80 gm/dL
ALBUMIN-# 3.19 gm/dL
AIG RATIO-66
Hemogram:
Hemoglobin-8.5 gm/dL
Total Count-7100 cells/cu. mm
Neutrophils-66%
Lymphocytes-22%
Eosinophils-2%
Monocytes-10%
Basophils-0%
PCV-27.2 vol %
MCV-72.5 fl
MCH-22.5 pg
MCHC-31.3%
RBC Count-3.72 millions/ cu. mm
Platelet Count-3.64 lakhs/cu. mm
TREATMENT:
1)Anti tuberculosis drugs 4pills/day
2)Tab Wysolone 20mg PO BD for 3 days followed by Tab Wysolone 20mg PO OD for 2 weeks
3)Neb.Budecort 1 respule 6th hourly.
Comments
Post a Comment