1801006129 long case

march 17,2023.TH A

79 Y/O MALE WITH RECURRENT CVA AND LEFT HEMIPLEGIA WITH ASPIRATION PNEUMONIA AND SEIZURES DISORDER.

CHEIF COMPLAINTS :-
A 79 year old male was brought to the OPD with cheif complaints:

.C/o altered sensorium since 5 days.

.  fever since 10 days

.complaints of cough since 20 days

. difficulty in swallowing since 1 month.

HOPI :-

Patient was apparently asymptomatic 20days back then  he developed cough which was insidious in onset and gradually progressive. The cough was productive but patient was not able to spit it out and he also faced Difficulty in swallowing.

20 days back ( on feb 25th) he started to have cough and cold

On march 3rd secretions got increased and he was unable to spit that out

After 2 days went to a hospital and got admitted for 5 days during which he got those secretions cleared out

H/o change of voice since 20 days, insidious, hoarse in character and 
Slurring of speech was seen.
H/o cough on intake of liquids.
No h/o hemoptysis, difficulty in breathing, breathlessness.

High grade Fever was since 10 days associated with Chills and rigours

There is no history of 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.  Tab zoryl mv , po/od

K/c/o CVA with left hemiplegia since 7 years.

K/c/o hypothyroidism since 5 years

K/c/o seizures disorder since 2 years 

. 10 years back , patient developed lesions on his both foot and out of no where and went to the doctor and found to have diabetes and was put on medication and after 1 year with regular check up he was diagnosed Hypertension and was put on antihypertensive medication.

.7 years back, patient developed head ache at morning, shoulder ache at evening and become sick by night followed by vomtings he was taken to the hospital, but on that night itself he developed left hand  pain and itching 

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

-On NEXT DAY Morning they took him to hospital And the Patient was able to lift his hand But was unable to hold objects.

. AFTER 3 DAYS patient developed left sided hemiplegia.

 An MRI report was taken and it showed 3 infarcts.

Patient stayed for one and half month in hospital and there was no improvement and so got discharged.

He took liquid deit for 3 months because the patient was unable to eat solid foods and then he slowly started eating solid foods.

patient has 2 attacks of Covid.

-> AFTER 3 YEARS [2020] He had Cough for 2days With Fever on 2nd day and was Diagnosed with covid this was the first time he got COVID for and it resolved

-> AFTER 1 YEAR [2021] He was Diagnosed with COVID for 2nd time and got it resolved.

after covid

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.

.From 7 years onwards , patient was bedridden with foleys attached to him and physiotherapy was done by his attenders daily, but there no improvement was seen

. 20 days back, from March 1st onwards patient developed slurring of speech, mild cough unable to clear the throat secretions and decreased responsiveness and was taken to the hospital and was treated with antibiotics and patient was brought here for further evaluation.

DRUG 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

PERSONAL HISTORY :-

Appetite - decreased 
diet - mixed 
Bowel-  Constipated
Bladder - regular
No known allergies and Addictions

Family History-  not significant

GENERAL EXAMINATION :-

O/e PT IS arousable but not oriented. Pt not cooperative mostly.

. 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

Respiratory:

respiratory movements equal on both sides

Trachea is  central

Bilateral air entry is present

Normal vesicular breath sounds

CNS EXAMINATION:

PATIENT is unconscious incoherent uncooperative.

HIGHER MENTAL FUNCTIONS- cannot be elecited

Speech 

Behaviour

Memory

Intelligence

MMSE score could  be done.

GCS( Glasgow coma scale)

E3V3M5

CRANIAL NERVES Examination:

1. CN1:
Sence of Smell - Normal

2. CN2:
visual acuity -  decreased on left side

3. 3,4,6 CN

EOM movement - could not perform 

Pupil size - 2, 3 mm
Direct light reflex/consensual light reflex/accommodation reflex - present, present
Ptosis - absent, absent
Nystagmus - absent, absent

. 5 CN
Sensory over face & buccal mucosa - N, N
Motor - masseter, Temporalis, pterigoids - N, N
Reflexes - Corneal,Conjunctival - N, N

7 CN 
Motor
Nasolabial fold - equal om both sides
Occipito frontalis - equal om both sides
Orbicularis oculi - equal om both sides
Orbicular oris - equal om both sides
Buccinator - equal om both sides

Sensory:
Taste over anterior two third of tongue - cant be performed 

MOTOR SYSTEM EXAMINATION :- could not be performed 

Power - could not be performed 

U/L ->

                   Right                  left

                 UL. LL.                     UL. LL

   BULK  :   Normal                    Reduced                            

   TONE.    Normal                   Hypotonia

Superficial reflexes -

Corneal - N, N
Conjunctival - N, N
Abdominal - N, N

PLANTAR REFLEX:

Left side: babinski positive.

DEEP TENDON RELEXES:

biceps right:

 

biceps left:

triceps left:

Cerebellar examination - could not be performed 
Finger Nose test
Finger finger test
Dysdiadokinesia
Heel knee test 
Tandem walking
Dysmetria
Intention tremor 
Rebound phenomenon
Nystagmus
Titubation
Rhombergs test
SIGNS OF MENINGEAL IRRITATION: absent

Sensory System examination - could not be performed 

Crude touch
Pain
Temperature

Posterior Column
fine touch
Vibration
position sense

Cortical -
Two point discrimination 
Tactile localization 
Graphesthesia
Stereognosis

Gait could not be done

Examination of other Systems - NAD +

CVS :-

Auscultation: 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
bed sores
C/o asymptomatic lesions all over the body since 2 months

H/o application of unknown topical medications used

On examination, multiple hyperpigmented lesions were seen all over the body with scaly lesions over the upper back
 Diffuse xerosis present
single ulcer of size 1.5x1.5 cm over the back.
Diagnosis - Senile Xerosis with post inflammatory hyperpigmentation.

A pressure ulcer was also seen at base of scrotum

clinical pictures:

INVESTIGATIONS:

HbsAg rapid - negative

Xray -

Blood urea -30mg/dl

HBA1C-6.7%

HIV 1/2 RAPID TEST - NON REACTIVE

Anti HCV antibodies rapid - nonreactive

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)

Electrolytes -
Sodium 135meq/l
Potassium 3.5 meq/l
Chloride 98meq/l
Calcium -1.06 mmol/l

PROVISIONAL DIAGNOSIS:-

Recurrent CVA with T2 DM,  hypertension with 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