1801006159 LONG CASE

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CASE: 

A 79 y/o male was brought to casuality with c/o cough since 20 days , 

fever since 10 days

difficulty in swallowing since one month

C/o altered sensorium since 3 days

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 20days back then he developed cough insidious in onset and gradually progressive productive but patient is not able to spit it out. 

Difficulty in swallowing.

Series of events as follows

* Patient developed cough and cold on 25th February 2023

* Took treatment for cold on March 1st

* There were increased secretions on  March 3rd but the patient was unable to spit it out

* Admitted in hospital from March 5th to March 10th and cleared secretions through suction.

H/O cough on intake of liquids.

H/O change of voice since 20 days, insidious, hoarse in character and  SLURRING OF SPEECH is present

No H/O difficulty in breathing, breathlessness, hemoptysis. 

Fever since 10 days - High grade. 

O/E Chills and rigors + (38 spikes).

N/H/O Vomiting, Chest pain, Loose stools.

10 years ago , 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 AGO(2016)

He developed head ache at around afternoon 2pm followed by vomtings and left hand itching and weakness.

PATIENT was awake on that night due to left hand weakness and itching

NEXT DAY 

MORNING they took him to hospital 

Patient can lift his hand 

But unable to hold objects

AFTER 3 DAYS

PATIENT became left sided hemiplegia.

MRI REPORT shows 3 INFARCTS

Patient stayed for 40 days in hospital and there was no improvement and discharged.

He took liquids for 3 months because patient is unable to eat solid foods. He then slowing started eating solid foods.

AFTER 1 YEAR (2017)

vomitings 

Fever 

Shivering for 3 days

 

Diagnosed with urinary tract infection 

Took treatment (antibiotics) for 5 days and it was resolved

AFTER 3 YEARS(2020)

Cough for 2 days 

Fever on 2 nd day

Diagnosed with covid

Infected with COVID for 1st time and resolved

After 1 year(2021)

 He was Diagnosed with COVID for 2nd time and resolved 

K/c/o seizures since 2 years; total no of episodes 3

1st episode 2 years back which is for 5 minutes patient eyes got rolled up and froth from mouth is noticed.patient is made to roll on his left ,seizures got subsided.

Next day morning he was taken to hospital after 3 hours stay in the hospital he got 2nd episode episode of seizures for 5 minutes.

3rd  episode has occurred after 3 hours in the hospital stay for 2 minutes.

79 Year old male who is a father of 4 children ( 2 sons and 2 daughters) used to run a shop ( kirana shop) for about 18 years.He stopped looking after his shop from 2006 and he was looked after by his sons. 

PAST HISTORY  

Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is on medications.

PERSONAL HISTORY 

Appetite - decreased 

Mixed - Diet

Bowel - Constipated, 

Bladder - Regular 

No known allergies and Addictions. i.e non alcoholic and non smoker

Family History

Not significant 

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 

On examination patient is arousable but not oriented.

Patient is not cooperative.

-PALLOR: PRESENT

NO  ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY,PEDAL EDEMA

VITALS ON ADMISSION 

Pulse Rate -b90 BPM

BP- 140/80MM HG

Respiratory Rate - 22 CPM

SPO2- 98%

GRBS - 183mg/dl

SYSTEMIC EXAMINATION

CNS

HIGHER MENTAL FUNCTIONS- cannot be elecited

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 Normal            Reduced                            

 TONE     Normal                      Hypotonia

 POWER     Could not be elicited

SUPERFICIAL REFLEXES

Abdominal reflex

plantar reflex  

Left side babinski sign positive

  DEEP REFLEXES

BICEPS, TRICEPS, SUPINATOR, KNEE ,ANKLE 

Biceps reflex on left side

Triceps reflex on left side

Ankle reflex on left side

CEREBELLAR EXAMINATION cannot be elicited

  Finger nose test

  Heel knee test 

  Dysdiadochokinesia

  Nystagmus

  Speech

  Rhombergs test

SIGNS OF MENINGEAL IRRITATION: absent

GAIT

 patient unable to walk

PERIPHERAL NERVES 

Trophic  ulcers are present

P/A

INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

AUSCULTATION: no bowel sounds heard

Respiratory 

respiratory movements equal on both sides

Trachea is  central

Bilateral air entry is present

Normal vesicular breath sounds

CVS:

S1 S2 heard , no murmurs

CLINICAL IMAGES:

DIAGNOSIS:

A left sided hemiplegia due to CVA 

INVESTIGATIONS:

CUE 

AFB-TRACE

PUS CELLS -2-4

EPITHELIAL CELLS -2-3

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 7.51

PCO2 29.5mmhg

Po2 67.5 mmhg

ELECTROLYTES

Sodium 135meq/l

Potassium 3.5 meq/l

Chloride 98meq/l

Calcium -1.06 mmol/l

ECG:

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.

Note: Poor quality of images due to motion artefacts

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.

8) TAB. THYRONORM 25MCG RT/OD

9) TAB. LEVIPiL