1801006104-LONG CASE

March18,2023

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

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 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.

 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.-> AFTER 1 YEAR [2017] He developed vomitings, Fever, Shivering  for 3 days and was Diagnosed with urinary tract infection 

For that he Took antibiotics for 5 days and it got resolved

-> 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 resolved 

-> 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

PERSONAL HISTORY :-

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

Family History-  not significant

TREATMENT 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

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

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
Percussion- BAE+

CRANIAL N. EXAMINCTION :-

1. CN
Sence of Smell - N

2. CN
visual acuity -  decreased on left side

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 

8 CN - could not perform 
Rinnes test
Webers test

9, 10 CN -
Uvula palatal arches movements - N, N
Gag reflex - N
palatal reflex - N

11 CN - could not be elicited 
Trapezius
Sternocleidomastoid

12 CN 
wasting - no
Fasciculations - no
Tongue protrusion to midline - midline

MOTOR SYSTEM EXAMINATION :- could not be performed 

Power - could not be performed 

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 br performed

Superficial reflexes -
Corneal - N, N
Conjunctival - N, N
Abdominal - N, N

DEEP REFLEXES: 

BICEPS, TRICEPS, SUPINATOR, KNEE ANKLE.

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 

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

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

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:-

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