1801006144-LONG CASE

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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 of cough since 20 days ,C/o altered sensorium since 3 days, difficulty in swallowing since 1 month and fever since 10 days

HISTORY OF PRESENTING ILLNESS :-

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 1st took treatment for 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 rigors

There is no history of vomiting, chest pain, loose stools.

events history:-

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 hospital and was thought to have a heart problem and sent back home, but on that night itself he developed leg 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.

For which he was admitted in hospital

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

One year back [2022]

He got seizures for 5min and they took him to the hospital.

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.

PAST HISTORY :-

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

K/c/o seizures disorder since 2 years

K/c/o hypothyroidism since 5 years and on thyronorm 25mcg Since 5 years

PERSONAL HISTORY :-

Appetite - decreased

diet - mixed

Bowel- constipation present

Bladder - regular

No known allergies and Addictions

Family History-  not significant

GENERAL EXAMINATION :-

PATIENT is unconscious incoherent

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

Trachea central

palpation : apical impulse in left  5th  intercostal space

Auscultation : normal vesicular breath sounds, bilateral air entry present

CNS 

PATIENT is unconscious incoherent uncooperative

HIGHER MENTAL FUNCTIONS- cannot be elecited

Speech 

Behaviour

Memory

Intelligence

Lobar functions

CRANIAL N. EXAMINCTION :-

1. CN

Sence of Smell - cannot be elecited

2. CN

visual acuity -  cannot be elecited

Corneal reflexe present

3,4,6 CN

EOM movement - cannot be elecited

Pupil size - 2, 3 mm

Direct and indirect light reflex - present, present

Ptosis - absent, absent

Nystagmus - absent, absent

5 CN 

cannot be elecited

Sensory over face & buccal mucosa - 

Motor - masseter, Temporalis, pterigoids -

Corneal reflux present

Jaw jerk-present

7 CN

Motor

Nasolabial fold - absent on right side

Occipito frontalis - cannot be performed

Orbicularis oculi - cannot be performed

Orbicular oris - cannot be performed

Buccinator - equal om both sides

Sensory:

Taste over anterior two third of tongue - ppt is not consciousness to perform

8 CN - cannot be elicited

Rinnes test

Webers test

9, 10 CN - cannot be elicited

Uvula palatal arches movements -

Gag reflex - intact

palatal reflex - 

11 CN - could not be elicited

Trapezius

Sternocleidomastoid

12 CN

wasting - present

Fasciculations - no

Tongue protrusion to midline -can be elicited

MOTOR SYSTEM EXAMINATION :- could not be elicited

Bulk reduced

Tone hypertonic left side

Power - cant be elicited

U/L

Shoulder -

Flexion - Extention

lateral - medial rotation

Abduction -Adduction

Elbows -

Flexion - Extension

Wrist -

DorsiFlexion - palmar flexitar

Adduction - Abduction

Pronation - Supination

Hand grip

L/L ->

Hip

Flexion- Extension

lateral rotation - Medial rotation

Abduction - Adduction.

Knees -

Flexion - extention

Ankle -

DorsiFlexion - plantar flexion

Inversion - eversion.

Trunk muscles - rolling over bed cannot be elicited

Superficial reflexes -

Corneal - N, N

Abdominal - N, N

Plantar response-

Deep Tendon reflexes -

Biceps

Triceps -

Knee -

Ankle -

https://youtube.com/shorts/bAwnwz6TUfM?feature=share

Cerebellar examination - could not be elicited

Finger Nose test

Finger finger test

Dysdiadokinesia

Heel knee test

Tandem walking

Rhombergs test

SIGNS OF MENINGEAL IRRITATION: absent

Sensory System examination - could not be performed

Spinothalamic tract

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 spine - normal

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

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

ABG -

Ph 7.51

PCO2 29.5mmhg

Po2 67.5 mmhg

PROVISIONAL DIAGNOSIS:-

Left side hemiplagia associated with right side facial palsy involving right middle cerebral artery and lesion is in right internal capsule

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.

7) TAB. LEVIPiL