1801006198- SHORT CASE

1801006198- SHORT CASE 

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A 79 yr old 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 vomitings, 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 - decreased

Mixed - diet

Bowel - constipated

Bladder- regular

No addictions.

FAMILY HISTORY:

Not significant.

TREATMENT HISTORY:

Tab TELMA AM 40 mg po/od since 10 yrs.

Tab zoryl mv po/od.

Tab levipil 500mg since 2 yrs.

Thyronorm 25mcg since 5yrs.

GENERAL EXAMINATION:

Patient is arousable but not oriented.

Patient is non cooperative.

No pallor,icterus,cyanosis, clubbing, lymphadenopathy,pedal edema.

VITALS:

Pulse rate: 75bpm

BP: 140/80 mmHg

RR: 22 cpm

Spo2 :98%

GRBS-183mg/dl

SYSTEMIC EXAMINATION:

CNS:

HIGHER MENTAL FUNCTIONS:

cannot be elicited.

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.                      Reduced                            

   TONE.     Normal                      Hypotonia

   POWER: Could not be elicited.

REFLEXES:

SUPERFICIAL REFLEXES: 

Left side babinski sign positive 

Deep reflexes:

CEREBELLAR EXAMINATION : cannot be elicited

  Finger nose test

  Heel knee test 

  Dysdiadochokinesia

  Rebound phenomenon .

  Speech

  Rhombergs test

SIGNS OF MENINGEAL IRRITATION: absent

GAIT: patient unable to walk

P/A

INSPECTION: 

Umbilicus is central and  inverted.

All quadrants are moving equally with respiration.

No scars, sinuses,engorged veins and visible pulsations.

AUSCULTATION: no bowel sounds heard

bed sores

CVS: 

S1 S2 Heard ,no murmurs.

RESPIRATORY:

 Respiratory movements equal on both sides

Trachea Central

normal vesicular breath sounds.

Bilateral air entry present.

Trophic ulcers are present:

Diagnosis:

Senile xerosis with   post inflammatory hyperpigmentation .

INVESTIGATION:

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.

 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- 7.5

PCO2: 29.5mmhg

PO2: 67.5 mmhg

Electrolytes :

Sodium: 135meq/l.

Potassium: 3.5 meq/l.

Chloride :98meq/l.

Calcium :1.06 mmol/l.

Diagnosis:

Left sided hemiplegia 

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