1801006184 CASE PRESENTATION
Long case
A 50 year old man resident of Miryalguda, worker in an ice factory and came with chief complaints of weakness of right upper limb and lower limb , slurring of speech and deviation of mouth to left side
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 month back then he developed giddiness for which he went to the local hospital and he was also diagnosed to be hypertensive for which he took medication for 20 days(Atenolol and Amlodipine) and stopped since 10 days.
On 13/03/2023 at morning 4 am he developed weakness of right upper limb and lower limb .He also developed slurring of speech and deviation of mouth towards left. He was taken to local hospital and was referred to our hospital.
No history of vomiting headache, unconsciousness,seizures,neck rigidity,valvular heart diseases
PAST HISTORY:
Patient has history of fracture to right elbow 30 years ago.
Known case of hypertension since 1month
No history of diabetes, tuberculosis, epilepsy
No history of trauma to head.
No history of surgeries.
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bowel and bladder: Regular
Addictions: Alcoholic since 30 yrs and chews tobacco (Gutka) for 10 years (one packet of gukta lasts for 2days)
DAILY ROUTINE :
Before illness:
4am- gets ready(has tea)and go for work
9am- have breakfast(rice, curry) and go back to work.
1pm- have lunch (rice dal ,curry ,chicken weekly thrice)and go back to work
9 pm- have dinner
10pm- sleeps
After the illness:
He went for work for 20 days and then stopped doing the work.His strength to do work has decreased.
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient was examined in a well lit room after taking informed consent. He is conscious, coherent and cooperative; moderately built and nourished.
Pallor- Absent
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Generalised lymphadenopathy- Absent
Edema- Absent
Vitals
1. Temperature- Afebrile
2. Pulse pressure- 75 beats per min
3. Blood pressure- 130/70 mm Hg
4. Respiratory rate- 17 cycles per min
5. GRBS-109mg/dl
SYSTEMIC EXAMINATION:
CENTRAL NERVOUS SYSTEM-
Dominance -Right handed
Higher mental functions-
Conscious
Oriented to time place and person
Memory- Immediate, recent and remote
Slurring of speech present
Cranial nerve examination:
I- Olfactory nerve- sense of smell Normal
II- Optic nerve-
Visual acuity
Field of vision. Normal
Colour vision normal
III, IV, VI. Right Left .
EOM Normal Normal
Diplopia. Absent Absent
Nystagmus Absent Absent
Ptosis Absent Absent
Direct and indirect
Light reflex present
V- Masseter, temporalis and pterygoid muscles are normal on both sides(sensations of face are normal can chew food normally)
VII- - Deviation of mouth to left side
VIII- no hearing loss ,no vertigo
IX- no difficulty in swallowing
X- No difficulty in swallowing
XI -sternocleidomastoid contraction present,
Trapezius- shrugging of shoulders against resistance present
Neck can move in all directions
XII - No deviation of tongue,tongue movements normal
Motor system
Tone Right. Left
Upper limb Increased. Normal
Lower limb Increased Normal
power. Right. Left
Upper limb 3/5 4/5
Lower limb 3/5 4/5
Superficial reflxes
Corneal reflex normal on both sides
Conjunctival reflex normal on both sides
Deep tendon reflexes Right Left
Biceps +++ ++
Triceps. +++ ++
Supinator +++ ++
Knee. Jerk +++ ++
Ankle jerk +++ ++
Plantar. Muted. Flexion
Positive. Negative
Sensory system
Spinothalamic Rt. Lft
Crude touch + +.
Pain + +
Temperature + +
Posterior column
Fine touch + +
Vibration Normal
Cortical
Two point discrimination- able to discriminate
Tactile localization -able to localise
Cerebellar Examination
Finger nose test-Normal
Heel shin test -Normal
Finger finger nose test -Normal
No Dysdiadochokinesia
No meningeal signs
Examination of spine-Normal
Deep tendon reflexes Right side
Biceps:
Triceps:
Knee jerk:
Ankle jerk:
Supinator:
Plantar reflex:
RESPIRATORY SYSTEM:
*Inspection-*
Shape of the chest- elliptical
B/L symmetrical,
Both sides moving equally with respiration
No scars, sinuses, engorged veins, pulsations
*Palpation-*
Trachea - central
Expansion of chest is equal on both side
Tactile vocal fremitus Normal
*Auscultation-*
Normal vesicular breath sounds heard
CARDIOVASCULAR SYSTEM
Inspection-
Shape of chest- elliptical shaped chest
No engorged veins, scars, visible pulsations
JVP is not raised
Palpation-
Apex beat in 5th inter costal space medial to mid clavicular line
No thrills and parasternal heaves felt
Auscultation-
S1,S2 are heard
no murmurs heard
ABDOMINAL EXAMINATION
Inspection-
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible. pulsations.
Hernial orifices- free.
Palpation-
soft, non-tender
No palpable spleen and liver
Percussion- Resonant note heard
Auscultation- Normal bowel sounds heard
RESPIRATORY SYSTEM:
Inspection-
Shape of the chest- elliptical
B/L symmetrical,
Both sides moving equally with respiration
No scars, sinuses, engorged veins, pulsations
Palpation-
Trachea - central
Expansion of chest is equal on both side
Tactile vocal fremitus Normal
Auscultation-
Normal vesicular breath sounds heard
Provisional diagnosis: cerebrovascular accident with right sided hemiparesis
INVESTIGATIONS
Anti HCV antibodies rapid - non reactive
HIV 1/2 rapid test - non reactive
Random Blood sugar - 109 mg/dl
Fasting blood sugar - 114 mg/dl
Hemoglobin- 13.4 gm/dl
WBC-7,800 cells/mm3
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/mm3
Platelet counts- 3.01 lakhs/ cu mm
Peripheral Smear
RBC - normocytic normochromic
WBC - with in normal limits
Platelets - Adequate
Complete Urine Examination
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
Liver Function tests
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
MRI
Tab.ECOSPRIN
Tab.CLOPITAB
Tab.ATOROVASTAT
Physiotherapy of right upper limb and lower limb
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short case
A 28 year old male resident of nalgonda a daily wage worker came to OPD with chief complaints of
Abdominal distention since 15 days
Shortness of breath since 10 days .
Yellowish discoloration of eyes since 15 days.
Bilateral leg swelling since 15 days.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 15 days back then he developed abdominal distention which is insidious in onset and gradually progressive since 15 days that increased on consuming food decreased on passing stools.
The patient also complains of shortness of breath grade 3 since 10 days
Patient has loss of appetite since 2 days due to abdominal tightness.
No history of pain abdomen
No history of chest pain , cough, cold
No history of orthopnoea, paroxysmal nocturnal dyspnoea.
No history of melena , haematemesis.
No history of epigastric and retrosternal burning sensation
No history of facial puffiness, burning micturition, decreased urine output. No history of confusion, drowsiness.
PAST HISTORY
VITALS:
Temperature - 98.2*c
PR :- 95bpm
RR : 22cpm
BP :- 130/80mm Hg
SPO2 :- 98%
GRBS :- 120mg/dl.
SYSTEMIC EXAMINATION
Per abdomen -
Inspection-
Abdomen is distended , flanks are full, umbilicus is slit like , skin is stretched , dilated veins present , no visible peristalsis , equal symmetrical movements in all quadrant’s with respiration
Palpation -
No local rise of temperature, no tenderness
All inspectory findings are confirmed by palpation, no rebound tenderness, gaurding and rigidity.
No tenderness , No organomegaly
Percussion -
Fluid thrill present
Auscultation-
Bowel sounds heard
CVS :
Inspection-
Chest is symmetrical , no dilated veins , scars and sinuses seen
Palpation -
Apical impulse felt at left 5th inter coastal space medial to mid clavicular line
Auscultation- S1 , S2 heard , no murmurs
RESPIRATORY SYSTEM:
Inspection-
Chest is symmetrical, trachea is central
Palpation -
Trachea is central ,
Bilateral chest movements are equal
Percussion - resonant in all 9 areas
Auscultation-
Normal vesicular breath sounds heard .
CENTRAL NERVOUS SYSTEM:
Higher mental functions - normal memory intact
cranial nerves :Normal
sensory examination:
Normal sensations felt in all dermatomes
motor examination-
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
reflexes-
Normal reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
cerebellar function-
Normal function.
INVESTIGATIONS :
Hemogram -
Hb- 13.2gm/dl
Total leucocyte count - 5000cells /cumm
Neutrophils - 71%
Lymphocytes -22%
RBC - 4.8 million /cumm
Electrolytes-
Sodium- 138mEq/l
Potassium - 4.4mEq/l
Chloride- 104mEq/l
Liver function tests -
Total bilirubin - 4.75mg/dl
Direct bilirubin - 2.11mg/dl
SGOT(AST) - 178 IU/L
SGPT(ALT) - 50 IU/L
ALP- 255IU/L
Total protein - 6.2 gm /dl
Albumin - 2.01 gm/dl
A:G ratio - 0.48
Ascitic tap -
Appearance - clear , straw coloured
SAAG - 1.79 g/dl
Serum albumin - 2.01 g/dl
Asctic albumin - 0.22 g/dl
Ascitic fluid sugar - 166mg/dl
Ascitic fluid protein - 2.1 g/dl
Ascitic fluid amylase - 20.8 IU /L
LDH : 150IU/L
Cell count- 150 cells
Lymphocytes 90%
Neutrophils 10%
PT - 15 seconds
INR - 1.4
aPTT - prolonged
CUE:
Appearance - clear
Albumin - trace
Sugars - nil
Pus cells - 2to 4
Epithelial cells - 1 to 3
RBC - nil
RFT :
Blood urea - 20mg/dl
Creatinine - 0.9mg/dl
X-ray
USG :
Impression- liver normal size
Altered echotexture with surface irregularities present suggestive of chronic liver disease.
DIAGNOSIS
Alcoholic liver disease.
TREATMENT PLAN:
1. Fluid restriction
2. Salt restricted normal diet
3. Inj.VITAMIN K 1 ampoule in 100 ml NS OD
4. Inj.THIAMINE 1amp in 100ml NS OD
5. Inj.PAN 40mg BD
6.Inj.ZOFER 4mgTID.
7.Syrup LACTULOSE 15ml 30 mins before food TID.
8. Tab. Aldactone 50mg OD
9. Tab. LASIX 40mg BD
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