long case
COMPLAINTS AND DURATION:
A 77 y/o male was brought with c/o cough since 1 & half month ,
difficulty in swallowing since one month
Fever since 10 days
C/o altered sensorium since 3 days
HOPI
Patient is a known case of cva with left hemiplegia, DM type 2 , Hypertension, hypothyroidism
Patient was apparently asymptomatic one and half month back when he developed cough insidious in onset and gradually progressive. PRODUCTIVE but patient is not able to spit it out. Difficulty in swallowing.
H/o cough on intake of liquids.
H/o change of voice since 20 days, insidious, hoarse in character and
SLURRING OF SPEECH +present
Fever since 10 days -high grade associated with Chills and rigors
H/O WEAKNESS in LEFT upper and lower limb since 7 years aggrevated since 4 days.
No history head trauma
No history of loss of consciousness
No history of transient loss of vision
No history of involuntary movements
No history of pain in calf muscles
No history of chest pain and loose stools
PAST HISTORY
Patient is a k/c/o Hypertension for which he is on Telmisartan 40 mg od since past 10years
Known case of diabetes mellitus since 10 yrs metformin,glimeperide and voglibose ( Zoryl mv 2)
History of events:-
• 10 years back , 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 back, patient developed head ache at around evening 7pm and followed by vomtings, next day morning after went to bathroom and when he layed back there was weakness in limbs after some time they was paralysis of limbs and was taken to the hospital and found to have infarct and started on antiplatelets.
K/c/o CVA with left hemiplegia since 7 years.
K/c/o seizures disorder since 2 years for which on medications Tab levipil 500mg
K/c/o hypothyroidism since 5 years on thyronorm 25mcg.
• From 7 years onwards , patient was bedridden with foleys (changed every 15 days) and physiotherapy was done by his attenders daily, but there was no such improvement.
• 20 days back, from March 1st onwards ,patient developed slurring of speech and decreased responsiveness and cough ( mild ) and unable to clear the throat secretions and was taken to the hospital and was treated with antibiotics and patient was brought here for further evaluation.
PERSONAL HISTORY
Appetite lost,
Mixed diet
Bowel- constipated,
Bladder regular
No known allergies and Addictions.
i.e non alcoholic and non smoker
Family History- not significant, no similar complaints in younger individuals
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
Patient is concious, oriented to time place and person
Pt not so cooperative
-NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
Position - supine position in bed
UL left - flexed , adducted and semipronated , lying helplessly
LL- left - extended , adducted and plantiflexed lying helplessly
Right sided upperlimbs and lower limbs within normal limit
VITALS ON ADMISSION
PR-90 BPM
BP- 140/80MM HG
RR- 22 CPM
SPO2- 98% AT RA
GRBS - 183mg/dl
SYSTEMIC EXAMINATION:
Respiratory system
Shape and movement of chest are normal
Trachea Central
Apex beat heard in 5th ICS
Bilateral grunting is present
Bilateral air entry present
CNS
Patient is concious not so coperative
GCS - E3 V3 M5
Patient is right handed
Emotionally unstable
Memory normal
Couldn't calculate
Speech- there is decrease in fluency, use less no.of words while talking , but he is able to understand the language and words
Patient is not able to read and write
Cranial nerve examination:
Rt. Lf
Olfactory nerve. Normal. Normla
Opthalmic nerve. Visual acuity by
Counting finger test
Pupils round and reactive on b both sides
Color vision normal on both sides
CN- 3,4&6- eye movement present in all directions and pupillary reflexes normal on both sides
Ptosis absent on both sides
Nystagmus absent on both sides
CN- 5 - trigeminal nerve
Sensory
Motor
Jaw jerk
CN-7 Fascial nerve
Fore head wrinkling present on both sides
Deviation of angle of mouth towards right Taste sensation in anterior 2/3 of tongue could not be elicited
CN-8 cannot be elicited
CN-9 cannot be elicited
CN-11 cannot be elicited
Trapezius
SCM
CN-12
Wasting present
Fasciculations absent
Tongue protrusion to midline can be elicited
Motor examination
Nutrition atrophy of muscles is seen on left upper and lower limbs
Power -
Right upper limb and lower limb-4/5
Left upper limb and lower limbs - 0/5
Upper limb-
Shoulder - abduction - addiction
Flexion and extension
Internal rotation and external rotation
Elbow flexion and extension
Wrist- dorsiflexion and palmar flexion
Adduction and abduction
Supination. And pronation
Hand grip
Hip - flexion and extension ;
Adduction and abduction
Internal and external rotation
Knee - flexion and extension
Ankle - dorsiflexion and palmar flexion
- inversion and eversion
Trunk muscles - rolling over bed cannot be elicited
Reflexes -
Superficial:
Corneal reflex normal on both sides
Conjunctival normal on both sides
Abdominal normal on both sides
Plantar - babinski sign is possitive on both the sides
https://youtu.be/QdK4uXIgKQI
Deep tendon reflexes -
Rt. Lf
Biceps +1. -
Triceps. -. -
Knee jerk -. -
https://youtu.be/IVzTWOMdKZ4
Ankle jerk
https://youtu.be/aQdjniYbcnQ
Cerebellar function tests could not be elicited
Signs of meningeal irritation absent
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 :-umbiliculs Central and everted
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.
bed sores are present
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,
Pseudobulbar palsy in query
Sepsis secondayr to pneumonia and UTI
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
45 year old male came to the OPD with
Chief complaints of:
Bilateral pedal edema since 12days
Shortness of breath since 5days
HOPI:
Patient was apparently asymptomatic 12days back then he developed bilateral pedal edema which was gradual in progression, extended upto knee and is of pitting type.
He also developed Shortness of breath which was initially grade 1 and progressed to grade 2 (nyha)
Associated with orthopnea
H/o loss of appetite since one week and nausea and vomitings three days back (3 episodes) non billious
No H/o- fever,burning micturation, diarrhoea decreased urine output
No H/o cough, hemoptysis,fever,
No h/o chest pain,giddiness , palpitations, decreased urine output, syncopal attacks,
No h/o abdominal distension, jaundice vomitings
Past history:
Not a K/C/o Diabetes Mellitus,Asthma,TB,epilepsy,leprosy,CAD
Treatment history
Not significant
Personal history:
Diet:Mixed
Appetite:Decreased
Sleep-adequate
Bowel movements-regular
Bladder movements- normal urinary output
Addictions-chronic alcoholic since 10 years and Tobacco smoking since 10 years.
Family history: Not significant
General examination:
Patient is conscious,coherent,cooperative and well oriented with time,place,person
Poorly nourished and thin built
No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy
Bilateral pedal edema is present,Upper limb edema
Vitals:Temperature: 98.4 degree Fahrenheit
BP-100/80mmHg
PR-104bpm
RR-21cpm
Grbs- 147mg/dl
Systemic examination:
Respiratory system:
Inspection-
Trachea-central
Chest appears b/L symmetrical and elliptical in shape
Palpation-
Trachea central in position
Measurements-
AP diameter-16cms
Transverse diameter-26cms
Percussion
Supraclavicular - Resonant on R&L
Infraclavicular - Resonant on R&L
Mammary - Resonant on R&L
Axillary - Dull on both right and left
Suprascapular - Resonant on R&L
Infrascapular - Dull on both right and left
Auscultation:
Decreased breath sounds at axillary and infrascapular region
CVS:
Inspection:
• Chest is bilaterally symmetrical.
•Trachea is central
•Movements are equal bilaterally
•. No parasternal haeve
JVP:Raised
•NO Visible epigastric pulsations
• No scars or sinuses
•Apical impulse seen in left 6th
intercostal space lateral to mid
clavicular line
Palpation:
•All inspectory findings are confirmed:
Trachea is central, movements equal bilaterally.
•Apex beat felt in left 6th intercostal space lateral
to midclavicular line
Para sternal heave not seen
Auscultation:
•S1 S2 heard
•No murmursPer abdomen:
•Scaphoid
•Visible epigastric pulsations
•No engorged
veins/scars/sinuses
•Soft , non tender
•No organomegaly
•Tympanic node heard all over
the abdomen
•Bowel sounds present
CNS:
•HMF - Intact
•Speech – Normal
•No Signs of Meningeal
irritation
•Motor and sensory system –
Normal
•Reflexes – Normal
•Cranial Nerves – Intact
•Gait – Normal
•Cerebellum – Normal
•GCS Score – 15/15
Provisional diagnosis:
Left heart failure ?with bilateral pleural effusion
Investigation:
Chest X-Ray:
Hemogram:
Hemoglobin-9.3gm/dl
Total count-12,800 cells/m3
Neutrophils-95%
Lymphocytes-62%
Eosinophils-0%
PCV-29.7 vol%
RDW-14.2%
USG:Bilateral moderate pleural effusion with collapse of underlying lobes.
ECG -
Blood sugar-80mg/dSerum creatinine:1.4gm/dl
Blood urea - 21 mg/dl
FINAL DIAGNOSIS-
heart failure with pleural effusion
Treatment
*Injection lasix 40 mg iv BD
* TAB Nicardia 10 mg po BD
* TAB DYTOR 20mg po.BD
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