1801006022 LONG CASE
79 y/o male with Recurrent CVA and left hemiplegia with seizures
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Chief complaints-
Cough since 20 days ,
Fever since 10 days
Difficulty in swallowing and h/o Aspiration pneumonia since one month
Altered sensorium since 3 days
History of Presenting illness
Patient was apparently asymptomatic 20 days ago.Then,he developed cough which was insidious in onset and gradually progressive,productive but patient was unable to clear throat secretions. He also had cold and drooling of saliva. He was treated with antibiotics till March 3rd
On March 5th, patient's wife noticed foaming at the mouth around 12 in the afternoon. He was admitted to a hospital in Nalgonda where he was treated with suction of throat secretions for 5 days. He was referred to this hospital for further evaluation
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
No h/o difficulty in breathing, breathlessness, hemoptysis
Fever since 10 days -high grade.
H/O WEAKNESS in LEFT upper and lower limb since 4 years aggrevated since 4 days.
N/h/o vomiting, chest pain, loose stools.
PAST HISTORY
Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is on medications I.e tab TELMA AM 40mg po/od.
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
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.
-9 years ago he was diagnosed with hypertension and started taking anti hypertensives
-7 years back, patient developed head ache at around evening 7pm and followed by vomtings, next day morning onwards patient became drowsy and cannot move his limbs and was taken to the hospital and found to have infarct and started on antiplatelets.
-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.
-6 years ago he had a urinary tract infection and was treated with antibiotics for 5 days
- 2 years ago he had 2 episodes of seizures not lasting longer than 5 min
PERSONAL HISTORY
Appetite reduced
Mixed diet
Bowel- constipated,
Bladder regular
No known allergies and Addictions.
Family History- Not relevant
Treatment history
•Tab TELMA AM 40mg po/od since past 10years
•Tab zoryl mv , po/od
•Tab levipil 500mg since 2 years
GENERAL EXAMINATION
O/w patient is conscious,incoherent and uncooperative
-PALLOR: PRESENT
-NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
VITALS ON ADMISSION
PR-90 BPM
BP- 140/80MM HG
RR- 22 CPM
SPO2- 98% AT RA
GRBS - 183mg/dl
SYSTEMIC EXAMINATION:
Respiratory :-
Inspection : Respiratory movements equal on both sides
palpation : Apex beat on left 5th intercoastal space
Auscultation : NVBS heard
percussion - BAE +
CNS
PATIENT WAS conscious,incoherent and uncooperative
HIGHER MENTAL FUNCTIONS- Could not be elicited
speech
Behavior
Memory
Intelligence
Lobar Functions
No hallucinations or delusions.
Cranial Nerve Examinations
II- Visual acuity reduced on left side
3,4,6- Pupillary reflex present
MOTOR EXAMINATION:
Right left
UL. LL. UL. LL
BULK Normal Normal Reduced
TONE Normal Hypotonia
POWER Could not be elicited
MOTOR SYSTEM:
B/L REFLEXES:
BICEPS, TRICEPS, SUPINATOR, KNEE ANKLE - hypotonia
PLANTARS- hypotonia
SENSORY EXAMINATION: Could not be elicited
SPINOTHALAMIC SENSATION:
Crude touch
pain-
temperature
DORSAL COLUMN SENSATION:
Fine touch
Vibration
Proprioception
CORTICAL SENSATION:
Two point discrimination
Tactile localisation.
CEREBELLAR EXAMINATION
SIGNS OF MENINGEAL IRRITATION: absent
GAIT:
B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT
CVS
ASCULTATION: S1S2 +,NO MURMURS
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
Clinical images
CUE :-
AFB- Trace
Pus cells- 2-4
Epithelial cells- 2-3
ABG
PH-7.51 mmHg
pC02-29.5 mmHg
p02-67.9 mmHg
Urea-30mg/dL
HbA1c-6.7%
X Ray Chest
ECG
2D Echo
DIAGNOSIS
Recurrent CVA with Hypertension, T2 DM, Thyroid disorder and seizures disorder
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 ,
MUCUMZY 8th hourly
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 TOOMG RT/OD
Credits
Durga Krishna Sir PG GM
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