1801006189 CASE PRESENTATION

 Long Case

A 35 yr old male came to opd with chief complaints :

yellowish discoloration of eyes since 15 days ,

abdominal distenstion since 15 days 

bilateral swelling of legs since 15 days , 

shortness of breath since 10 days .

HISTORY OF PRESENTING ILLNESS :

patient was apparently asymptomatic 15 days back then he developed abdominal distenstion which is insidious in onset and gradually progressive since 15 days and he has bilateral lowerlimb swelling below knee since 15 days .patient is having breathlessness for 10 days for regular household activities like using toilet, while brushing , walking within home , patient is having itching over all the body since 10 days .

patient has loss of appetite apetite since 1 week .

NO history of abdominal pain.

NO history of chest pain , palpitations, orthopnea 

NO history of cough , hemoptysis .

No histroy of melena , hemetemesis .

NO history of epigastric and retrosternal burning sensation .

No history of facial puffiness , burning micturition, decreased urine output .

NO history  of confusion , drowsiness.

No history of diarrhoea.

PAST HISTORY:

patient has similar complaints in the past 5 months back and he developed yellowish discoloration of eyes for 3days ,fever was high grade , continuous not associated with chills and rigor , no evening rise of temperature, he went to hospital for 1 week and symptoms subsided after a week following which he continued consuming alcohol since then (180ml per day)

NOT a known case of diabetes, hypertension, asthma , TB , CAD.

PERSONAL HISTORY:

Diet :Mixed

Appetite : decreased 

Sleep :normal

Bowel and bladder : constipation is present 

Addictions: patient consuming alcohol 180 ml per day since 5 yrs. Non smoker.

FAMILY HISTORY:

NO similar complaints in the family.

GENERAL EXAMINATION:

patient is conscious,coherent, cooperative and well oriented to time ,place and person moderately built and nourished.

Pallor: absent

Icterus: PRESENT

cyanosis :absent 

clubbing : absent 

Edema : Bliateral pitting type of pedal edema is present.

lymphadenopathy:absent

 

VITALS:

Temperature: 98.4*C

pulse rate: 95 bpm

Respiratory rate :22cpm

SpO2: 98%

GRBS :120 mg/dl

STSTEMIC 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 quadrants with respiration.

Peripheral signs of chronic liver disease:

Spider naevi is absent

Palmar erythema is absent

Dupuytrens contracture is absent

Clubbing is absent

Bruises absent

Gynaecomastia absent

fetor hepaticus absent 

PALPATION :

No local rise of temperature, no tenderness 

All inspectory findings are confirmed by palpation, no rebound tenderness, guarding and rigidity .

No tenderness, spleen palpable in left hypochondrium.

No organomegaly 

PERCUSSION-Fluid thrill present 

Shifting dullness - absent 

AUSCULTATION: Bowel sounds are present .

No bruits .

CVS :

INSPECTION:

chest is symmetrical, no dialated 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 normal 

Bilateral chest movements are equal 

PERCUSSION:

Resonant in all 9 areas 

All quadrants are moving equally 

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

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

PT - 15 seconds

INR - 1.4 

aPTT - prolonged 

X-RAY:

USG : 

Impression- liver normal size

Altered echotexture with surface irregularities present suggestive of chronic liver disease.

Mild spleenomegaly.

DIAGNOSIS

Alcoholic cirrhosis with portal hypertension.

Decompensated features are jaundice and ascites .

currently no hepatic encephalopathy or hepatorenal syndrome .

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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short case

55 year male patient farmer by occupation presented with cheif complaints of: 

- Slurring of speech since 10 days

-deviation of mouth towards left side since 10days

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic  10 days ago then he developed slurring of speech  and deviation of mouth towards left side which were sudden in onset non progressive and no loss of sensation over limbs and face.Patient is has no complaints at night and sleeps peacefully.WAKES up in the morning with complains of stroke facing difficulty in speaking (he is able to talk but opposite person couldnot understand) difficulty in eating . 

No h/o trauma

No h/o drooling of saliva

No h/o difficulty of combing hair,mixing food, squatting,climbing stairs, rolling in bed,lifting up neck.

No h/o of upper and lower limb weakness.

No h/o blurring of vision.

No h/o loss of consiousness.

No h/o altered sensorium.

PAST HISTORY 

Patient is a known case of hypertension since 1 year.History of perforation to the tympanic membrane 15 years ago.History of tuberculosis 21 years ago and took medication for 6 months.

PERSONAL HISTORY 

Patient takes mixed diet,appetite is decreased,bowel and bladder movements are normal.Addictions : Patient has NO addictions at present,but 20 years ago he used to consume TODDY.No known allergies

DAILY HISTORY 

He wakes up at 5 am and does his routine work and have his break fast at 8 am goes to work.He will Have his lunch at 1 -2 pm.He reaches home at around 8 pm has dinner and goes to sleep.

FAMILY HISTORY

Father was a known case of Diabetes ,Hypertension and Tuberculosis and he passed away due to COVID.Mother passed away due to breast cancer.Both the sons of the patient were also affected with tuberculosis at the same time.Both his sisters are known case of diabetes and Hypertension.Brother , sister in law,and both their children were affected with tuberculosis.Brother had history of stroke 3 years back.

GENERAL EXAMINATION 

Patient is consious ,coherent ,cooperative and well oriented to time place and person.He is well built and well nourished.

pallor - absent

icterus  - absent

cyanosis - absent

clubbing - absent     

 lymphadenopathy - absent

edema - absent

VITALS

Pulse rate-60 bpm

Respiratory rate- 18 cpm   

Blood pressure- 130/80mmHg

Temperature- afebrile

On examination of head to foot, there no presence of neurocutaneous markers,congestive cardiac failure.

SYSTEMIC EXAMINATION 

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher mental function-conciousness,oriented to time place and person.
SPEECH - slurring of speech present, no fluency
Memory - Normal,No delusions or hallucinations

CRANIAL NERVE EXAMINATION :-

I- Olfactory nerve-sense of smell is present

II- Optic nerve-direct and indirect light reflex is  present

III- Oculomotor nerve IV- Trochlear nerve and VI- Abducens- direct and consenual light reflex, accomodation reflex are  present, no diplopia, no nystagmus, no ptosis.

V- Trigeminal nerve

Sensory: sensation present over face.

Motor-Masseter,temporalis and pterygoid muscles are normal.

Reflex- Corneal reflex, conjunctival reflex and jaw jerk is present.

VII- Facial nerve-loss of nasolabial fold on right side and mouth deviated to left side.

VIII- Vestibulocochlear nerve- decreased hearing of the left ear 

(rinner’s negative for 256 Hz and 512 Hz) and normal hearing of the right ear.

No nystagmus

IX- Glossopharyngeal nerve- palatal movements present and equal.gag reflex present

 X- Vagus- palatal movements present and equal

XI- Accessory nerve- trapezius, sternocleidomastoid contraction present

XII- HYPOGLOSSAL NERVE - DEVIATION OF TONGUE TOWARDS RIGHT SIDE

MOTOR SYSTEM 

1) Bulk                         right                   left

-appearnace               normal             normal

-palpation                    normal            normal

-measurements

Upper limb -(arm)        29cm                29cm

              (Fore arm)      26cm               25 cm

Lower limb-( thigh)       49cm               49 cm

                    Leg)         31 cm               31 cm

2) Tone-

Upper limb-                  normal              normal

 Lower limb-                  normal.            normal 

3) Power-

  Upper limb-

        Shoulder               5/5                   5/5

        Elbow                   5/5                   5/5

       Wrist                      5/5                   5/5 

Lower limb-

       Hip                        5/5                  5/5

       Knee                     5/5                  5/5

         Ankle                        5/5                  5/5

       Leg                       5/5                  5/5

4) Reflex:

       Biceps reflex           2+                2+

       Triceps reflex          2+                2+

       Knee reflex             2+                2+

       Ankle reflex

       Plantar                  flexion           flexion

SENSORY SYSTEM-

Crude touch -present

 Pain - present

Temperature- present

Fine touch- present

Tactile localisation-present

2 point discrimination-present

CEREBELLAR SYSTEM-

NO gait ataxia

Nystagmus-no

Dysarthria-present

Intention tremor-absent

Limb coordination tests:

Finger nose test, heel shin test are normal.

dysdiadochokinesis

MENINGEAL SIGNS-

No neck stiffnes,no kernigs and brudzinsky sign

CARDIOVASCULAR SYSTEM EXAMINATION 

INSPECTION-chest wall appears normal in shape and symmetrical,no visible pulsations,scars,dilated veins.

PALPATION- apical impulse felt at 5 ICS .

AUSCULATION-s1 s2 heard nor murmurs heard

RESPIRATORY SYSTEM-

INSPECTION -chest wall normal shape and symmetrical movement with repiration, no dilated veins,no scars

PALPATION- trachea central,Chest wall movements symmetrical, tactile vocal fremitus symmetrical.

PERCUSSION - resonant,no pain and tenderness

AUSCULTATION -normal vesicular breath sounds heard ,no addent sounds.

ABDOMEN EXAMINATION 

INSPECTION - abdomen round ,umbilicus in center not everted,no visble sinuses and scar,no visible peristalsis,

PALPITATIONS -no pain and tenderness no organomegaly

AUSCULTATION -bowel sounds  heard

PROVISIONAL DIAGNOSIS 

Sudden onset ,left sided dense hemiplegia with left upper motor neuron facial palsy due Acute cerebrovascular accident involving lenticulostriate branch of left mca territory probably due to thrombus and patient has a risk factor of hypertension 

INVESTIGATIONS 

Complete blood picture

 Hemoglobin:11.7mg/dl

Peripheral smear: normocytic normochromic anemia

Red blood cells:3.86

Pcv:34.6

Platelet count:2.10

Total leucocyte count:5,100

Fasting blood sugar : 92 mg/dl

Serum creatinine :1.3 mg/dl

Blood urea 38 mg/dl

CUE:

Colour : pale yellow

Appearance : clear

Reaction :acidic

Albumin:nil

Sugar: nil

Bile salts and bile pigments : nil

RBC : nil

Crystals :nil

Casts : nil

pus cells:2-3

epithelial cells-2-3

Serum electrolytes 

Sodium: 145 mEq/L

Potassium:4.2mEq/L

Chloride:104 mEq/L

Calcium ionized:1.11 mmol/L

CAROTID DOPPLER

MRI REPORT 

Infarcts in left internal capsule

TREATMENT 

TAB.CLOPITAB 75mg 

TAB. Ecospirin 75mg