1801006191 CASE PRESENTATION

 long case


A 65 years old male , resident of Narketpally, alcohol seller & shepherd by occupation presented to the OPD 4 days back with cheif complaints of :
- Fever since 3 days 
- Cough since 3 days 

History of presenting illness :

The patient was apparently asymptomatic 7 years back, then he developed giddiness for which he went to the hospital and was diagnosed with type 2 diabetes for which he was prescribed Metformin 500 mg .

Then, 6 months back patient had developed pitting type of pedal edema upto the knees and was diagnosed to have chronic kidney disease with left upper ureter calculi . Surgery was planned but couldn't be done as the patient was unfit for surgery and therefore, was managed conservatively .

He has been having dry cough occasionally since 6 months .

Then he developed fever 3 days back that was insidious in onset , low grade , associated with chills and weight loss . 
Then he also developed productive cough that was sudden in onset, with sputum that was mucoid in nature, non foul smelling, non blood tinged .
No history of loose stools 
No history of vomitings , abdominal pain 

Past History: 

Known case of chronic kidney disease .
Similar episodes of fever lasting for 4-5 days which is relieved on medication.

Not a known case of hypertension, asthma, epilepsy, coronary artery diseases, thyroid disorders .

Personal history :

Daily routine :

He wakes up at 6 am in the morning, takes his sheep out for grazing and then returns home at around 9 am . He has his breakfast and opens his liquor shop by 11 am .He returns home at around 1 pm , has his lunch and again returns back to his shop . He then comes back home at 9 pm at night, has his dinner and sleeps .

He consumes a mixed diet.
He has a good appetite .
He has adequate sleep .
Bowel and bladder movements are regular .

He used to drink whisky 90 - 180 ml/day but since 6 months, he is only drinking occasionally during festivals .

Family history : There are no similar complaints in the family .

General Examination : 

Patient is conscious, coherent, cooperative, well oriented to time, place and person .

Pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and pedal edema are absent.





VITALS :

Temperature : afebrile
Blood pressure : 120/86 mm Hg
Pulse rate : 80 bpm 
Respiratory rate : 18 cpm

Systemic Examination :

Respiratory system examination :

Upper respiratory tract :

Oral cavity is normal
Dental carries absent
Nasal septum is central
No post nasal drip

On inspection :
- The chest is bilaterally symmetrical .
- Both sides of chest are moving equally with respiration .

On palpation :
- Expansion of chest is symmetrical .
- Position of trachea is central .
- Tactile vocal fremitus - decreased on right side
- AP diameter 16 cm 
- Transverse diameter 23 cm
- Transverse diameter/Anteroposterior diameter ratio = 23/16 = 1.4
( Normally, 7/5 = 1.4 )

On percussion -  Dull note on right mammary, infra-axillary, interscapular, infrascapular .

R = resonant 

On auscultation - bilateral air entry present, normal vesicular breath sounds are heard, vocal resonance is normal .
Decreased breath sounds in right mammary, infra-axillary, interscapular, infrascapular .

Cardiovascular system examination :

On inspection :
. The chest wall is bilaterally symmetrical, there are no skeletal deformities.
. There are no dilated and engorged superficial veins .
. Apical pulsation present, there are no other pulsations .

On palpation :
• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line. 
• JVP was normal 
• No parasternal heave

On auscultation ‐ S1, S2 heard , no murmurs

Abdominal examination : soft, non tender, no organomegaly, bowel sounds heard .

Central nervous system examination :

Higher mental functions are intact
All cranial nerves are intact
Motor system is normal
Sensory system is normal
Cerebellar signs are absent
No signs of meningeal irritation 

Provisional diagnosis : Respiratory disease 

Investigations :

CUE :
Albumin ++
Sugars +++

Pleural fluid analysis :

Volume = 3 ml
Pale yellow, cloudy
750cells/mm3 - 30% neutrophils, 70% lymphocytes
RBCs - nil
ADA - 83.6 IU/L


Chest X - Ray



Final Diagnosis : Right sided pleural effusion (maybe secondary to TB ? )

 Treatment :

Anti tubercular drugs :
Isoniazid 5 mg/kg/weight
Rifampicin 10mg/kg/weight
Ethambutol 20 mg/kg/weight
Pyrazinamide 20-25 mg/kg/ weight 
4 tablets a day fixed dose .


----------------------------------------------------------------------------------------------------------------------------------------------------
short case

A 50 year old male , ice factory worker by occupation, from Mirualguda presented to the casualty with weakness of right upper and lower limbs  with slurring of speech and deviation of mouth to the left side since the morning of 13/3/23 4am.  

History of presenting illness :
Patient was apparently asymptomatic 1 month back, he then developed giddiness followed by a fall. He was taken to the hospital and was diagnosed with hypertension for which he used medication only for 20 days and then was non compliant after that .
The patient then developed sudden onset of weakness in his right upper and lower limbs that was associated with deviation of the mouth to left side and slurring of speech.

There is no complaint of unconsciousness, difficulty in swallowing, sensory disturbances, headaches, nausea, vomiting, seizure episodes , no bladder or bowel incontinence .
There is no complaint of neck rigidity.

Past history :
History of trauma to the right elbow due to a fall from the tree 30 years ago ,so he cannot extending his right hand completly.

He is a known case of hypertension since 1 month who was compliant to medication only for 20 days .

Not a known case of diabetes, coronary artery diseases, epilepsy .

Family history : No similar complaints in the family

Personal history  :

Daily routine of the patient :

The patient wakes up at 4:30am in the morning has tea and goes to work in the ice factory. He lives in quarters given in the factory itself. He comes back home around 1 pm to have his lunch which is usually rice, curry and dal. 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 6:00 pm following which he comes home, has his dinner and sleeps by 8:30 pm.

The patient has been chewing tobacco for around 10 years. 1 packet of tobacco lasts for 2 days. 

He consumed alcohol on a regular basis since 30 years. He stopped for around 3 years and started again 6 months ago.

Bowel and bladder movements are regular.

Treatment history :

He was on Amlodipine and Atenolol for only 20 days .

General Examination : 

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

Pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and pedal edema are absent.

VITALS :

Temperature : afebrile
Blood pressure : 140/80 mm Hg
Pulse rate : 86 bpm 
Respiratory rate : 18 cpm




Systemic Examination :

Central nervous system examination :

Higher mental functions :

• conscious
• oriented to time, person and place
• memory - immediate,recent,remote intact
•slurring of speech present 

Cranial nerves :

I - can smell normally 

II - no visual disturbances

III, IV, VI - Able to move eyes in all directions                     - Direct and indirect light reflexes are                     present 
               - Accomodation reflex present .

V - Sensations of face are normal 
    - Can chew food normally 
    - Corneal and conjunctival reflexes are                  present 
    - Jaw jerk present 

VII - Deviation of angle of mouth to the left side
      - Presence of wrinkling on the right forehead when asked to frown
      - Taste sensation is normal from the anterior two thirds of tongue 

VIII - Hearing is normal
       - No vertigo or nystagmus 

IX , X - Pharyngeal reflex is present 

XI - Able to shrug his shoulders on both sides          against resistance 

XII - tongue movements normal, no deviation or fasciculations 

Motor : 

BULK - there is no wasting or atrophy of the muscles 

POWER
                                  Right.                     Left
Upper limb.                 4/5.                        5/5

Lower limb.                  4/5.                         5/5

TONE
                                      Right.                    Left
Upper limb.               Hypertonia.             Normal
Lower limb.               Hypertonia.              Normal

REFLEXES 
                                     Right.                      Left

Biceps.                          +3.                          +2



Triceps.                         +3.                           +2





Supinator.                       +3.                          +2




Knee.                              +3.                           +2





Ankle.                             +3.                            +2



Babinski's sign            Positive.            Negative
                                   ( Abnormal ).      ( Normal )



Sensory :

- Pain, temperature, crude touch are normal
- Fine touch, vibration, proprioception are normal
- Two point discrimination - able to discriminate
- Tactile localisation - able to localise 

Cerebellar signs :

- Vertigo - absent
- Nystagmus - absent
- Intention tremors - absent
- Slurred speech - present
- Hypotonia - absent
- Dysdiadochokinesia - absent 

Signs of meningeal irritation :

- Neck stiffness, Brudzinski's sign, Kernig's sign are absent 

Cardiovascular system examination :

On inspection :
. The chest wall is bilaterally symmetrical, there are no skeletal deformities.
. There are no dilated and engorged superficial veins .
. Apical pulsation present, there are no other pulsations .

On palpation :
• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line. 
• JVP was normal 
• No parasternal heave

On auscultation ‐ S1, S2 heard , no murmurs 

Respiratory system examination  :

On inspection :
- The chest is bilaterally symmetrical .
- Both sides of chest are moving equally with respiration .
- There are no dilated and engorged superficial veins .

On palpation :
- Expansion of chest is symmetrical .
- Position of trachea is central .
- Tactile vocal fremitus - normal

On percussion - resonant note heard on both sides of the chest .

On auscultation - bilateral air entry present, normal vesicular breath sounds are heard, vocal resonance is normal .

Abdominal examination : soft, non tender, no organomegaly, bowel sounds heard .

Provisional diagnosis : Cerebrovascular accident with right sided hemiparesis 

Investigations :

Fever chart


Anti HCV antibodies - non reactive 

HIV 1/2 rapid test - non reactive

Blood sugar random - 109 mg/dl 

FBS - 114 mg/dl


Hemogram :

Hemoglobin- 13.4 gm/dl

WBC-7,800 cells/cu mm

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/cumm

Platelet counts- 3.01 lakhs/ cu mm


CUE:

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 


LFTs:

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

T3 - 0.75 ng/ml 

T4 - 8 mcg/dl 

TSH - 2.18 mIU/ml

Treatment : 

- Tablet Ecosprin 75 mg PO
- Tablet Clopitab 75 mg PO OD
- Syrup Cremaffin plus 15 ml PO
- Physiotherapy of the right upper and lower limb 

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