18100006010 CASE PRESENTATIONS

 LONG CASE:


A 45 year old male, daily wage labourer came to the casuality with  

CHIEF COMPLAINTS :

Imbalance while walking   since 3 days

      associated with Swaying to both the sides since 3 days.

Involuntary movements of the extremities since 3 days.

HISTORY OF PRESENT ILLNESS:

patient was apparently asymptomatic 3 days back then in the morning after he had his

 breakfast he noticed 

*imbalance while  walking along with swaying on both the sides which was sudden in

 onset, progressive in nature , associated with generalized weakness and falls without loss of

 consciousness. 

*involuntary movements of the extremities particularly upper limbs since 3 days,

 symmetrical, which  was aggravating while trying to reach an object and relieving with 

rest,interrupting with his daily activity.

No history of buckling of limbs

No history of stiffness of limbs

No history of difficulty in getting up from squatting position

No history of any difficulty in rolling over the bed.

No history of otorrhea or any  hearing loss  or any earache.

No history of giddiness or lightheadedness or palpitations, dry skin

No history suggestive of wash basin attack

No history of difficulty in wearing slippers or any slippage of chappals.

No history of any root pain or paresthesias or numbness

No history of  neck pain or neck stiffness or blurring of vision or projectile vomitings.

No history of urinary incontinence or retention or diarrhea or constipation.

No history of any speech abnormality or anything suggestive of  cranial nerve abnormality.

No history of fever or headache

No history of waxing or wanning of symptoms.

No history of any behavioural changes 

No history of weight loss or loss of appetite.

No history of intake of toxins.

No history of joint pains or rash

No history of bulky stools or loose stools.


PAST HISTORY:

Known case of epilepsy and on medication since 8 yrs(Tab PHENYTOIN 100MG/TID)

Not a known case of diabetes or hypertension or thyroid problems or tuberculosis.

No history of any serious illness in the past or any hospital admission 

No history of similar complaints in the past.

DRUG HISTORY:

History of excessive intake of phenytoin in the past 20 days for the fear of precipitating  seizures.

PERSONAL HISTORY:

Regular diet

Regular bowel and bladder

Disturbed sleep since past 1 month( due to anxiety and depression probably due to   loss of 

his brother)

Occasionally Alcoholic.

Occasional Smoker : smokes 1 pack (20 cigarretes) in a week ,0.5 pack years

FAMILY HISTORY:

Born on non consanguinous marraige.

achieved appropriate developmental milestones.

No history of similar complaints in the family.


SUMMARY:

Case of a 45 Year old male with symmetrical bilateral Ataxia , sudden in onset,

I would like to consider the possibility of Acute cerebellar Ataxia without the involvement 

of  sensory, motor ,autonomic or cranial nerve involvement.

GENERAL EXAMINATION:

Patient is conscious ,coherent and cooperative , comfortably  lying on bed. 

Well built, moderately nourished, BMI of  22kg/m2.

No pallor/ icterus /cyanosis/clubbing/ kylonychia /lymphadenopathy/edema

Hypertrophy of the gums present.

No signs of Neurocutaneous markers or any skin rash

No hyperpigmentation of knuckles.

No signs of nutritional defeciency like chelitis or angula stomatitis or purpura or thinning 

of hair or dermatitis or bruising.

No spine abnormalities

No signs of skeletal deformities like pes cavus , short neck.

No detectable KF rings or sunflower cataract or telangiectasias.

VITALS :

PULSE : regular rhythm

               82 BPM

               good volume

               normal charecter

               normal vessel wall thickening

               no radioradial or radiofemoral delay.

               peripheral pulses felt.

BLOOD PRESSURE: right arm supine position.

                                     132/90mm of hg

RESPIRATORY RATE: 22CPM, regular, abdominothoracic type.

TEMPERATURE         : afebrile

               

SYSTEMIC EXAMINATION:

CNS :

Right Handed person, studied upto 10th standard.

HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

MMSE 26/30

speech : normal

Behavior : normal 

Memory : Intact.

Intelligence : Normal

Lobar Functions : Normal.

No hallucinations or delusions.

CRANIAL NERVE EXAMINATION:

1st   : Normal

2nd  :  visual acuity is normal

           visual field is normal

            colour vision normal

            fundal glow present.

3rd,4th,6th  :  pupillary reflexes present.

                      EOM full range of motion present

                      gaze evoked Nystagmus present.

5th             :  sensory intact

                      motor intact

7th             :  normal

8th             :  No abnormality noted.

9th,10th     : palatal movements present and equal.

11th,12th   : normal.

MOTOR EXAMINATION:                     Right                                           Left

                                           UL                            LL                      UL                    LL

   BULK                         Normal                    Normal                 Normal          Normal

   TONE                          hypotonia                hypotonia             hypotonia      hypotonia

   POWER                       5/5                          5/5                         5/5                 5/5

   SUPERFICIAL REFLEXES:

   CORNEAL                                    present                                            present       

   CONJUNCTIVAL                         present                                            present

   ABDOMINAL                                                             present

   PLANTAR                                     withdrawal                                      withdrawal

   DEEP TENDON REFLEXES:

   BICEPS                        2                                2                         2                       2

   TRICEPS                      2                                2                         2                       2

   SUPINATOR                2                                2                         2                       2

   KNEE                            2                               2                         2                       2

   ANKLE                         1                               1                         1                        1

    

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch

pain

temperature

DORSAL COLUMN SENSATION:

Fine touch

Vibration

Proprioception

CORTICAL SENSATION:

Two point discrimination

Tactile localisation.

steregnosis

graphasthesia.



CEREBELLAR EXAMINATION:

  Finger nose test

  Heel knee test 

  Dysdiadochokinesia

  Dysmetria

  hypotonia with pendular knee jerk present.

  Intention tremor present.

  Rebound phenomenon .

  Nystagmus

  Titubation

  Speech

  Rhombergs  test

SIGNS OF MENINGEAL IRRITATION: absent

GAIT:

wide based with reeling while walking, unsteady with a tendency to fall

unable to perform tandem walking.

CVS EXAMINATION:

   S1 S2 Present

  No murmurs or added sounds

RESPIRATORY SYSTEM EXAMINATION:

  Bilateral airway entry

  No added sounds.

PER ABDOMEN EXAMINATION:

  Soft and nontender.

  No organomegaly present.

FINAL DIAGNOSIS:

FUNCTIONAL :       ATAXIA

ANATOMICAL:      CEREBELLUM

PATHOLOGICAL:

ETIOLOGICAL:     ? DRUG INDUCED(PHENYTOIN)


WORKUP:

CBP:

        HB  11.2

        TLC  12000

       PLATELET  2.02L

ESR    23

LFT    Within normal limit

RFT    Within normal limit

ECG   




CXRAY








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SHORT CASE-1:

A 60 years old female presented to the casualty with complaints of  fever associated with chills and abdominal pain.

CHIEF COMPLAINTs

➤Fever for the past 6 days.

➤Pain abdomen for the past 3 days


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6 days ago after which she developed high grade fever associated with chills, insidious in onset, progressive, not subsiding with medication, continuous type

Pain abdomen , sudden in onset,  pricking type, in the epigastrium and right hypochondrium which gets aggravated on right lateral position and relieved with sitting posture, associated with nausea and reduced appetite, no association with intake of fatty food

No complaints of burning micturition.

No complaints of cough, cold or shortness of breath.

No complaints of heartburn or flatulence.

No complaints of heamatemesis or maleana.

No complaints of dysphagia.

No complaints of  constipation or diarrhoea.

No history of yellowish discolouration of eyes or high coloured urine.

No history of weight loss

No history of any blood transfusion

No history of any high risk behaviour


HISTORY OF PAST ILLNESS 

   Not a known case of hypertension, diabetes, bronchial asthma, epilepsy.

   k/c/o tuberculosis and took complete treatment.

   No history of similar complaints in the past.


DRUG HISTORY

➤No significant drug history or intake of toxins.

 

PERSONAL HISTORY

Occupation: Daily waged labor working in Cotton fields.

➤Patient is married

➤Patient takes mixed diet but has a decreased appetite.

➤Bowel and bladder movement is normal and regular.

➤occasional  Alcoholic , non smoker.

- sound sleep


FAMILY HISTORY 

➤No significant family history.


MENSTRUAL HISTORY:

G 3 P 4 L 4 A 0

Attained menarche at the age of 20 years, with good flow and volume.

Attained menopause at age of 42 years.



SUMMARY:

60 year old female with high grade fever  and  abdominal pain confined to

 right upper quadrant  ,acute in onset, without any alcohol history  .

Possibly case of 

1) Acute Liver  injury (?infective etiology)

2)Acute Cholecystitis.


GENERAL EXAMINATION 

Patient is well built, well nourished.

Pallor : Not seen

Icterus :  Not seen

Cyanosis :  Not seen

Clubbing :  Not seen

Lymphadenopathy :  Not seen

Edema :  Not seen

- No signs of chronic liver cell failure

- No signs of nutritional deficiency.

VITALS

Temperature : 101℉

PR : 108 beats per minute

BP : 100/70 mmHg

RR : 24 cycles per minute

SpO2 : 95% in room air

Blood Sugar (random) : 100mg/dl


SYSTEMIC EXAMINATION 

ABDOMINAL EXAMINATION


INSPECTION

Shape - Scaphoid, with no distention.

Umbilicus  - Inverted

➤Equal symmetrical movements in all the quadrants with respiration.

➤No visible pulsation,peristalsis, dilated veins and localized swellings.

PALPATION

➤SUPERICIAL :Local rise of temperature in right hypochondrium with tenderness

 and localised guarding and rigidity.


➤ DEEP : Mild enlargement of liver, regular smooth surface  , rounded

 edges soft in consistency, tender, moving with

 respiration non pulsatile

No splenomegaly

➤Abdominal girth : 78cms.

➤xiphesternum to umbilicus distance was equal to umbilicus to pubic distance.

PERCUSSION

➤Hepatomegaly :  liver span of 16 cms with 4 cms extending

 below the costal margin

➤Fluid thrill and shifting dullness absent 

➤puddle sign absent

➤Traubes space : resonant

 AUSCULTATION

➤ Bowel sounds present.

➤No bruit or venous hum.

NO LOCAL LYMPHADENOPATHY

PER VAGINAL AND PER RECTAL EXAMINATION : NAD 

   

 

CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent.,

➤No cardiac   murmurs


RESPIRATORY SYSTEM

➤Normal vesicular breath sounds heard.

 ➤Bilateral air entry present


CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent

PROVISIONAL DIAGNOSIS :  

ACUTE HEPATITIS (? INFECTIVE)


INVESTIGATIONS : 

DAY 1

Serum Na+ 126
Serum K+    4.7
Serum Cl-    92
Serum Creatinine  0.8
Blood urea             40
CUE             normal
CBP :  HB  10.7
           TLC  13900
           PLATELET 4.02L
LFT :   TB        2.45
            DB       1.59
            SGOT  52
            SGPT  10
            ALK P  191
            ALB      2.5
PT/INR             17/1.2
APTT                33SECS
ESR                  110

BLOOD CULTURES    Showed no growth.

                                                 USG ABDOMEN




USG REPORT IMPRESSION-
Multiple liver abscess with largest measuring 5*5 cms in the 7th segment of liver , with 40 to 50% of liquefaction , hepatomegaly with liver span of 18.5 cms.



CT SCAN




















XRAY CHEST-POST TB CHANGES



FINAL DIAGNOSIS :

MULTPLE  PYOGENIC LIVER ABSCESS WITH ACUTE LIVER FAILURE.


TPR CHART





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SHORT CASE-2:

A 48 yr old male, farmer by occupation & resident of Nakrekal came to casualty with


CHEIF COMPLAINTS:

1.Swelling in the right lower limb since 20 years
   associated with pain 
2.Fever since 1wk
3.Loose stools  since 4 days (4 episodes/day)


HISTORY OF PRESENT ILLNESS  :

Patient  was apparently asymptomatic 20years back then, he developed

1) SWELLING IN THE RIGHT  LOWER LIMB :
 
 -Patient is a known case of filariasis with right leg swelling since 20    years which gets aggravated with rest and subsided with walking     intermittently also associated with fever spikes which gets relieved   with  medication
- Patient had a trauma over right lower limb 4 days back, following      which patient noticed increased swelling over right leg  with           ulceration and pus discharge associated with pain of pricking type.
 

2) FEVER :

- Low grade, intermittent type, associated  with chills & rigors, since    1 week & relieved by medications.
- He got admitted for the same in a nearby hospital and was told that
  his platelet count is low for which he was recieving conservative   
  treatment, as he could'nt afford the charges so was shifted here.

3)LOOSE MOTIONS:

-Patient had loose motions since 4 days , upto 4 episodes per day,
  not blood stained, non mucoid, low volume, non foul smelling. 


 No history of body pains, abdominal pain, head ache.
 No history of nausea ,vomitings or diarrheoa.
 No history of oliguria or burning micturition.

PAST HISTORY: 

- No similar complaints in the past

-Not a k/c/o DM, HTN, Asthma, TB, Epilepsy.

-No history of any drug usage or intake of toxins.

FAMILY HISTORY - 

-No significant family history 


PERSONAL HISTORY- 

- Diet              :mixed
- Appetite       :normal
- Sleep            : adequate 
- Bladder        : regular.
- Bowel          : diarrheoa since 4 days.
- Addictions   : Absent 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative. 
well built, moderately nourished.
- No pallor 
- No icterus 
- No clubbing, cyanosis 
- No koilonychia
- No lymphadenopathy
- No Edema 
- No rashes, Petechiae & Bleeding manifestations 
-Tourniquet test - Negative 

VITALS :

1.Temperature : Afebrile 
2. BP               : 100/70mmHg
3. PR               : 74 bpm
4. RR              :  24cpm.

SYSTEMIC EXAMINATION :

PER ABDOMEN:

- No distended abdomen
- No abdominal tenderness
- No engorged veins
- Guarding & rigidity absent
- Bowel sounds present.

RESPIRATORY SYSTEM:

-Bilateral airway entry present
-No added sounds

CVS :
- S1S2 Heard
- No thrills no murmurs

CNS:
-No abnormality noted
- Higher mental functions intact.

LOCAL EXAMINATION:









PROVISIONAL DIAGNOSIS :

-ELEPHENTIASIS WITH CHRONIC LYMPHEDEMA
-DENGUE FEVER

 FEVER CHARTING  :


SURGERY REFERRAL:






INVESTIGATIONS :

HEMOGRAM:

DATE : 4/08/21

- TOTAL WBC COUNT - 5,250 cells/cumm ( N - 4,000 to 10,000 cells/cumm)
- PLATELET COUNT  - 1.99 lakhs/cumm ( N - 1.5 - 4.1 lakh/cumm)
- PCV - 38.3% ( N - 40 - 50 %)

- 6/08/21

- TOTAL WBC COUNT - 3,500 cells/cumm 
- PLATELET COUNT  - 1.25 lakhs/cumm
- PCV - 46%

- 7/08/21

TOTAL WBC COUNT - 2,150 cells/cumm 
- PLATELET COUNT  - 44,000 cells/cumm 
- PCV - 39%

- 8/08/21 (MORNING)

- TOTAL WBC COUNT - 3,650 cells/cumm 
- PLATELET COUNT  - 39,000 cells/cumm 
- PCV - 39.4%

- 8/08/21 (EVENING)

- TOTAL WBC COUNT - 4,200 cells/cumm 
- PLATELET COUNT  - 60,000 lakhs/cumm 
- PCV - 39.1%

- 9/08/21 (Morning)


Evening 


DENGUE RAPID TEST 


MALARIAL PARASITE  TEST 


LFT


CUE


RBS


BLOOD UREA 


SERUM CREATININE 


SERUM ELECTROLYTES 





ECG 


TREATMENT 

DATE - 08/08/21

1. IVF @ 75 Ml/hr 
- 1. NS
- 1. RL
- 1. DNS
2. TAB PCM 650 MG X PO X TID
               1 - 1 - 1
Check temperature before giving pcm 
3. TEMPERATURE CHARTING 4TH HRLY
4. GRBS CHARTING 6TH HRLY
5. I/O CHARTING 

DATE - 9/09/21

1. IVF @ 75 Ml/hr 
- 1. NS
- 1. RL
- 1. DNS
2. TAB PCM 650 MG X PO X TID
               1 - 1 - 1
3. TAB AUGMENTIN 625 MG X OD X BD
4. TAB PAN 40 MG X OD
5. TAB MVT ORAL OD
6. TAB VIT C ORAL OD
7. TAB DOLO 650 MG ORAL (SOS)
8. Check temperature before giving pcm 
9. TEMPERATURE CHARTING 4TH HRLY
10.GRBS CHARTING 6TH HRLY
11. I/O CHARTING 

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