1801006159 CASE PRESENTATION

long case

A 79 y/o male was brought to casuality with c/o cough since 20 days ,

fever since 10 days

difficulty in swallowing since one month

C/o altered sensorium since 3 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 20days back then he developed cough insidious in onset and gradually progressive productive but patient is not able to spit it out.

Difficulty in swallowing.

Series of events as follows

* Patient developed cough and cold on 25th February 2023

* Took treatment for cold on March 1st

* There were increased secretions on March 3rd but the patient was unable to spit it out

* Admitted in hospital from March 5th to March 10th and cleared secretions through suction.

H/O cough on intake of liquids.

H/O change of voice since 20 days, insidious, hoarse in character and SLURRING OF SPEECH is present

No H/O difficulty in breathing, breathlessness, hemoptysis.

Fever since 10 days - High grade.

O/E Chills and rigors + (38 spikes).

N/H/O Vomiting, Chest pain, Loose stools.

10 years ago , patient developed lesions on his both foot and went to the doctor and found to have diabetes and started on medication and after 1 year ,with regular check up he was found to be Hypertensive and started on antihypertensive medication.

7 YEARS AGO(2016)

He developed head ache at around afternoon 2pm followed by vomtings and left hand itching and weakness.

PATIENT was awake on that night due to left hand weakness and itching

NEXT DAY

MORNING they took him to hospital

Patient can lift his hand

But unable to hold objects

AFTER 3 DAYS

PATIENT became left sided hemiplegia.

MRI REPORT shows 3 INFARCTS

Patient stayed for 40 days in hospital and there was no improvement and discharged.

He took liquids for 3 months because patient is unable to eat solid foods. He then slowing started eating solid foods.

AFTER 1 YEAR (2017)

vomitings

Fever

Shivering for 3 days

Diagnosed with urinary tract infection

Took treatment (antibiotics) for 5 days and it was resolved

AFTER 3 YEARS(2020)

Cough for 2 days

Fever on 2 nd day

Diagnosed with covid

Infected with COVID for 1st time and resolved

After 1 year(2021)

He was Diagnosed with COVID for 2nd time and resolved

K/c/o seizures since 2 years; total no of episodes 3

1st episode 2 years back which is for 5 minutes patient eyes got rolled up and froth from mouth is noticed.patient is made to roll on his left ,seizures got subsided.

Next day morning he was taken to hospital after 3 hours stay in the hospital he got 2nd episode episode of seizures for 5 minutes.

3rd episode has occurred after 3 hours in the hospital stay for 2 minutes.

79 Year old male who is a father of 4 children ( 2 sons and 2 daughters) used to run a shop ( kirana shop) for about 18 years.He stopped looking after his shop from 2006 and he was looked after by his sons.

PAST HISTORY

Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is on medications.

PERSONAL HISTORY

Appetite - decreased

Mixed - Diet

Bowel - Constipated,

Bladder - Regular

No known allergies and Addictions. i.e non alcoholic and non smoker

Family History

Not significant

Treatment history

Tab TELMA AM 40mg po/od since past 10years

Tab zoryl mv , po/od

Tab levipil 500mg since 2 years

Thyronorm 25mcg. Since5 years

GENERAL EXAMINATION

On examination patient is arousable but not oriented.

Patient is not cooperative.

-PALLOR: PRESENT

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY,PEDAL EDEMA

VITALS ON ADMISSION

Pulse Rate -b90 BPM

BP- 140/80MM HG

Respiratory Rate - 22 CPM

SPO2- 98%

GRBS - 183mg/dl

SYSTEMIC EXAMINATION

CNS

HIGHER MENTAL FUNCTIONS- cannot be elecited

Speech

Behaviour

Memory

Intelligence

Lobar functions

GCS- E3V3M5

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION

CRANIAL NERVES - cannot be examined

SENSORY SYSTEM- cannot be elicited

Spinothalamic sensation

Crude touch

Pain

Temperature

Dorsal column sensation

Fine touch

Vibration

Propioception

Cortical sensation

Two point discrimination

Tactile localisation

Stereognosis

Graphathesia

MOTOR EXAMINATION

Right Left

UL LL UL LL

BULK Normal Normal Reduced

TONE Normal Hypotonia

POWER Could not be elicited

SUPERFICIAL REFLEXES

Abdominal reflex

plantar reflex

Left side babinski sign positive

DEEP REFLEXES

BICEPS, TRICEPS, SUPINATOR, KNEE ,ANKLE

Biceps reflex on left side

Triceps reflex on left side

Ankle reflex on left side

CEREBELLAR EXAMINATION cannot be elicited

Finger nose test

Heel knee test

Dysdiadochokinesia

Nystagmus

Speech

Rhombergs test

SIGNS OF MENINGEAL IRRITATION: absent

GAIT

patient unable to walk

PERIPHERAL NERVES

Trophic ulcers are present

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

Respiratory

respiratory movements equal on both sides

Trachea is central

Bilateral air entry is present

Normal vesicular breath sounds

CVS:

S1 S2 heard , no murmurs

CLINICAL IMAGES:

DIAGNOSIS:

A left sided hemiplegia due to CVA

INVESTIGATIONS:

CUE

AFB-TRACE

PUS CELLS -2-4

EPITHELIAL CELLS -2-3

Anti HCV antibodies rapid - Nonreactive

Blood urea - 30mg/dl

HBA1C- 6.7%

HbsAg rapid - Negative

HIV 1/2 RAPID TEST - NON REACTIVE

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)

ABG

Ph 7.51

PCO2 29.5mmhg

Po2 67.5 mmhg

ELECTROLYTES

Sodium 135meq/l

Potassium 3.5 meq/l

Chloride 98meq/l

Calcium -1.06 mmol/l

ECG:

MRI BRAIN:

IMPRESSION:

• Large area of encephalomalacia in right occipito-temporo lobes and right parietal lobes - sequelae of old infarct.

• Diffuse cerebral atrophy. Chronic small vessel ischemia.

Note: Poor quality of images due to motion artefacts

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.

8) TAB. THYRONORM 25MCG RT/OD

9) TAB. LEVIPIL

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short case

A 49 year old female came with chief complaints of pain in the joints since 10 years.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 years back.She then developed fever (on and off type) for which she takes paracetamol (2-3 everyday).She had 2-3 episodes of vomiting,headache and increased frequency of micturation(15-20 times a day).

She then developed pain and swelling in her wrist,ankle,shoulder,elbow,hip,metacarpal phalanges,metatarsal joints and lower back which is radiating to both her legs till feet for which she was taken to the hospital.The medication prescribed to her provided her temporary relief.

She also complaints of pedal edema and stiffness in the joints as soon as she wakes up in the morning.

She has stopped her medication one month back.

DAILY ROUTINE:

She wakes up at 6:00 am in the morning.She takes a head shower everyday as she believes that it reduces her headache.She does the household chores,gets groceries and cooks food.She works at her farm from afternoon to evening and occasionally sells the produce in the market.Later in the night she cooks dinner and sleeps by 8:00pm.

PAST HISTORY:

Not a known case of Diabetes mellitus,Hypertension,Asthma,epilepsy

PERSONAL HISTORY:

Diet: used to have a mixed diet but now she stopped consuming meat

Apetite: decreased apetite

Sleep: reduced

Increased frequency of micturation(15-20 times a day)

Addictions: none

GENERAL PHYSICAL EXAMINATION:

Pallor:present

Icterus:absent

Cyanosis:absent