18100006006 CASE PRESENTATIONS

 LONG CASE:

Chief complaints

 A 28 year old male came with chief complaints of sudden fall followed by weakness of both the lower limbs (paraplegia) and loss of hand grip 10 days back, associated with bowel and bladder incontinence.

History of present illness:

Patient was apparently asymptomatic 1 month back, following which he developed productive cough, low grade fever for which he underwent sputum studies and tested positive for AFB bacilli and started ATT - HRZE regimen, 2 tab according to weight/PO/OD.

He developed generalized weakness and myalgia 15 days back.

10 days back, patient got up from bed and went to open the door and suddenly fell down, with no loss of consciousness and no froathing. Following which his brother got him up and since then Patient developed bowel and bladder incontinence.

weekness in both upper and lower limbs

lower limbs - able to move toes of bilateral lower limbs

                      unable to turn in the bed

                      unable to get from lying position

                      unable to walk

                      unable to lift his legs off the bed

upper limbs - unable to take comb to the head

                     unable to hold plate or glass, button or unbutton the shirt

                     unable to lift bucket

                     unable to eat food

                      able to move fingers and lift hand till his mouth

weekness is symmetrical and progressive.

no diurnal variation in weekness

no breathlessness, no ptosis and  no facial weekness

no difficulty in chewing.

fall - no loss of counsciousness

        not associated with involuntary movements,tongue bite and rolling up of eyes

        not preceded by chest pain, palpitations and sweating

        not associated with headache, giddiness, presyncope or visual disturbances

patient also complained of electric shock like sensation all over the body 

initially he experianced shock like pain only in the neck which radiated to bilateral upper limbs when neck is flexed

and paresthesia and tingling sensation over hands

no history of disorientation, any abnormal behaviour

no speech disturbances 

no loss of smell

visual acuity normal and colour vision - normal

no history of double vision and deviation of eyes to one side

no decreased or abnormal sensations over face

no difficulty in mastication

no deviation of angle of mouth, no drooling of saliva and no difficulty in closing eyes

no hearing impairment, no vertigo and tinnitus

no dysphagia, dysarthria, no nasal reguirgitation and horseness of voice

no difficulty in shrugging of shoulders

no deviation of tongue

sensory - able to feel cloths over the body

                able to feel hot and cold water during bath

                electric shock like sensation all over body

                paresthesia and tingling over bilateral hands

bowel and bladder incontinence is seen

Past history:

He is a known case of TB since 1month and on ATT - HRZE

Not a known case of DM,HTN, ASTHMA, EPILEPSY, THYROID DISORDERS, STROKE, CAD.

Personal history:

Diet - mixed

Appetite - normal

Sleep - Adequate

Bowel and bladder incontinence + since 1 week

No allergies 

No addictions

Family history:

His father is a known case of TB and used ATT for 2 years

Diagnosis ;

anatomical - cervical spinal cord

functional - quadriparesis

etiological - tuberculosis

pathological - compressive extramedullary and extradural leison

General examination:

Patient is conscious, coherent, co-operative and oriented to time, place and person

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy and edema.

Temperature - afebrile

PR - 80 BPM

RR - 16 cpm

BP - 100/70 mm Hg  

 

height - 165cm

weight - 45 kgs

BMI - 16.5kg/m2

Systemic examination:

CNS: 

Higher mental functions; 

patient is conscious, oriented to time, place and person, cooperative and comfortably lying on bed.

registration - normal

calculation - normal

no speech abnormalities - normal comprehension 

                                          naming of objects - normal

                                          no writing and reading abnormalities

                                          repetition - normal

                                          no dysarthria

cranial nerve examination - normal

No signs of meningeal irritation

 

MOTOR  SYSTEM  EXAMINATION 

lower limbs are  extended at knee joint

upper limbs are in mid flexed position

 

bulk of muscles - symmetrical on both sides ( no wasting or no hypertrophy)

                 Right.        Left

Tone. UL.  N.              N

           LL  increased. Increased

Power UL.  4/5.         4/5

             LL.  0/5.          0/5

Reflexes:

            Right.         Left

Biceps. 3+.             3+

Triceps. 3+.            3+

Supinator. 2+.         2+

Knee.          3+.         3+

Ankle.        3+.          3+

Plantar: extensor

SENSORY  SYSTEM  EXAMINATION

pin prick sensation and touch sensations are normal

pain and temperature sensations are normal

vibration sense over fore head, mastoid, clavicle, sternum, vertebral spine, tibial tuberosity and ankle is lost 

joint position at great toe and thumb is absent

 

CEREBELLUM

no nystagmus

no intentional tremor

finger nose test, finger nose finger test and knee shin dragging tests could asses due to quadriparesis

no hypotonia

no speech abnormalities

no pendular knee jerk

no titubation

CVS:

S1, S2 heard

No thrills

No Murmurs

Respiratory system:

Trachea - central

BAE +

NVBS heard

No added 

Per abdomen:

Soft, non tender

Bowel sounds - heard

Hernial orifices - normal

No palpable masses

Provisional diagnosis:

Cervical myelopathy?

Potts spine?

Investigations:

Treatment given:

1. Inj. Optineuron 1Amp in 100ml NS  IV/OD

2. Inj. Thiamine 200mg in 100ml NS IV/TID

3. ATT - according to body weight 2 tab PO/OD

4. Bp/ PR/ Spo2/ Temp charting

Update:

FINAL DIAGNOSIS:   Quadreparesis secondary to infectious spondylitis of C4, C5, C6, C7 and D1 with Epidural abscess at C5 - C6 level.

   UPDATE: 

He had surgical drainage of abcess at Osmania and getting discharged tomorrow

Outcome of intervention : 

Patient regained control over bowel and bladder, 

Improvement in power and tone..( as he is walking now) 

Adviced to continue ATT.       

                                                   

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SHORT CASE- 1:

A 32 year old male patient, autodriver by occupation came to OPD with chief complaints of

           Pedal edema since 10 days

           Less urine output since 10 days

HISTORY OF PRESENT ILLNESS

The patient was asymptomatic one year ago and developed diminision of vision consulted doctor and was diagnosed with hypertension for which he has been using Tab.Arkamin and Tab.Telma H since 1 year.

He developed pitting type of edema below the knee since one month, weakness and backache since one month which relieved on rest.

He has decreased urine output and consumes alcohol [180ml] rarely.

HISTORY OF PAST ILLNESS

known case of CKD on MHD since 1 month

Known case of HTN since 1 year (on Tab.Arkamin , Tab Terma H)

Not a known case of DM,CAD,Asthma,TB,Epilepsy

PERSONAL HISTORY

He is single

Occupation – Daily Labourer

Diet – Mixed

Appetite – Normal

Bowels – Regular

Micturition – decreased urine output

Has no known allergies

Drinks alcohol rarely[180ml]

TREATMENT HISTORY

No specific treatment history

FAMILY HISTORY

His brother is a k/c/o HTN

DRUG HISTORY

He has been using Tab.Arkamin and Tab.Telma H since 1 year for HTN.

GENERAL EXAMINATION

Patient was conscious,coherent,cooperative and examined in a well lit room.

VITALS

Pulse rate : 98bpm

Respiratory rate : 18/min

BP : 150/80mmHg

Temperature : Afebrile

GRBS : 127mg%

SpO2: 98% at room air

PHYSICAL EXAMINATION

 Pallor – absent

Icterus – absent

Cyanosis – absent

Clubbing of fingers/toes – absent

Lymphadenopathy – absent

Edema of feet – present,below the knee, pitting type.

Malnutrition – absent

Dehydration – absent

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

S1 and S2 heard
No thrills
No cardiac murmurs
RESPIRATORY SYSTEM

Vesicular breath sounds heard
Trachea is in central position
No wheezing
No Dyspnoea 

 ABDOMEN

Obese shaped abdomen
No tenderness
No palpable mass
No hernial orifices
No free fluid
Liver and spleen not palpable
Bowels sounds are heard

CNS

Conscious and normal speech
Normal gait
Cranial nerves normal
Sensory system normal
Motor system normal

REFLEXES

                      RIGHT         LEFT

 Biceps            +2                   +2

Triceps            +2                   +2

Supinator     +2                    +2

Knee                +2                    +2

Ankle              +2                   +2

INVESTIGATIONS

    28/07/2021

                                                                 ULTRASOUND

ECG

   29/07/2021

                                                                              ECG

2D ECHO

        

    30/07/2021

                                                       HEMOGRAM

 

PROVISIONAL DIAGNOSIS

         CKD on MHD secondary to Hypertensive nephropathy

  DIAGNOSIS       

            Heart failure with preserved ejection fraction

PLAN OF MANAGEMENT

      Renal Transplantation

        Discussion is going on regarding ABO Compatibility

TREATMENT

Fluid restriction <1L/day

Salt restriction <2.4L/day

T.Lasix 40mg PO/BD

SAM – 4pm

T.Nicardia 20mg PO/TID

T.Arkamine 0.1 mg PO/BD

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SHORT CASE-2:

80 year old Female who has sedentary life style without much physical activity, has been diagnosed with Hypertension 5 years back, she was put on Telma H - 40/12.5mg since then. Patient was apparently symptomatic till August 2nd night, then she experienced

Two episodes of loose stools which has foul smell, yellow in color,  sticky in consistence, and there is no associated tenesmus, also experienced

Three episodes of vomiting, no odor, food particles seen, non bile stained, and non projectile

As her daughter-in-law is a pharmacist, she gave her eldoper capsule and then stools subsided but patient developed fever with chills and rigor associated with vomiting next day morning, after patient has visited Narketpally KIMS hospital where she was treated with I.V fluids, ORS, Sporolac and other symptomatic treatment 

Upon enquiry she has explained us that her daily water intake used to be boiled Sagar water but on this particular day she drank Sagar water without boiling, all her family members used to drink filter water. None of the people in the same community have experienced any illness who drank Sagar water without boiling.

Patient is conscious, coherent and co-operative, heavy built and moderately nourished

Upon general examination from head to toe, 

Hair is thin and grey in color

Eyebrows, eyes, nose, lips appear normal

Neck short with double chin

Truncal obesity present

Hands and legs appear normal

 Vitals

BP - 90/60 mm of hg

Pulse rate - 100 bpm

Temperature - 103 degree Fahrenheit

GRBS - 126 mg/DL

Respiratory rate - 20 cycles/min

SPO2 - 96% at room air

Pallor - Present

No cynosis, No clubbing, No icterus, No edima, No lymphadenopathy

Tongue dry, Skin Turgor lost, Capillary refilling time - 5secs

Systemic Examination

Cardio Vascular System - S1 and S2 heard, No thrills, No cardiac murmurs

Respiratory System

Vesicular breath sounds heard

Trachea is in central position

No wheezing

No Dyspnoea

Central Nervous System

Conscious and normal speech

Normal gait

Sensory and Motor system examination - normal

ABDOMEN

Obese

Abdomen is soft, non tender, No palpable mass, no organomegaly

Hernial orifices - normal

Bowel sounds - Present

PROVISIONAL DIAGNOSIS - acute gastroenteritis with known case of hypertension

On the first day of admission 

five episodes of loose stools, three episodes of vomiting, fever with chills, temperature 103 degree Fahrenheit

Treatment Given

IV fluids

Inj. PANTOP 40mg OD

inj. ZOFER 4mg IV SOS

T. DOLO 650mg TID

inj. MONOCEF 1gm IV BD

inj. METROGYL 100ml IV TID

T. SPOROLAC DS TID

inj. NEOMOL 1gm IV SOS (If temp > 101degree Fahrenheit)

Mix ORS Sachet in 1litre water, drink 200ml after each episode of loose stool

INVESTIGATIONS

Hb - 8.8 gm/dl

Total WBC count - 9100 cells/cumm 

Neutrophils - 80%

Lymphocytes - 15%

PCV - 25.5% decreased

Platelet count - 1.76 lakhs/cumm

Serum Creatinine - 2.2 mg/DL

Blood Urea - 69 mg/DL

Sodium - 136 mEq/L

Potassium - 3.2 mEq/L

Chloride - 97 mEq/L

Total Billurubin - 1.18 mg/dl

Direct Billurubin - 0.36 mg/dl

SGOT(AST) - 24 IU/L

SGPT(ALT) - 17 IU/L

ALP - 180 IU/L

Total Proteins - 6.5gm/dl

Albumin - 3.4 gm/dl

USG

Raised echogenicity with grade-1 renal paramchymal changes in bilateral kidneys

on subsequent days of admission 

frequency of loose stools increased (10 to 14)episodes in a day

vomotings and fever subsided

same treatment was continued 

inj. optineuron and T. redotil were added

stool microscophy revealed few inflamatory cells

stool culture was negative

hanging drop test did'nt show any motility of organisms

hanging 

QUESTIONS

Is stool culture helpful in management of acute gastroenteritis

when to start antibiotics in acute gastroenteritis