1801006023 - LONG CASE
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CASE
This is a case of a 50 year old male, a resident of Miryalguda, factory worker by occupation, presented with the chief complaints of -
Weakness of right upper and lower limbs with slurring of speech and deviation of mouth to the left since 3 days
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 30 years ago. He then sustained a fracture close to his right elbow. He currently cannot extended his elbow completely.
1 month ago he developed giddiness and weakness of left upper and left lower limb which was sudden in onset followed by fall. He was then taken to the hospital where he was treated for the same and diagnosed with hypertension. His symptoms resolved in around 3 days. The patient was compliant with his hypertension medication for 20 days and stopped taking it after that.
The patient then developed weakness of right upper limb and lower limb 3 days ago which was sudden in onset. He noticed the weakness on his right side when he woke up in the morning. He felt unsteady as he stood up after waking up.
The weakness of right side was also associated with slurring of speech and deviation of the mouth to his left side. He was taken to a hospital nearby where he underwent a CT scan. He was then referred to our hospital the next day.
There is no history of difficulty in swallowing, behavioural abnormalities, fainting, sensory disturbances, fever, neck stiffness, altered sensorium, headache, vomiting, seizures, abnormal movements, falls.
PAST HISTORY:-
He is known case of hypertension from past 1 month
No history of diabetes, asthma, TB, epilepsy, coronary artery disease, or any thyroid abnormalities.
PERSONAL HISTORY:-
( daily routine )
The patient wakes up at 4:00am in the morning daily. He has tea and goes to work in the ice factory. He lives very close to the ice factory. He comes home and has breakfast at around 8 to 9 am. He usually has rice and curry for breakfast. He then goes back to work and comes home for lunch at around 2:00 pm. He usually has rice with curry and dal for lunch. He consumes chicken or mutton thrice weekly. He sometimes takes a nap in the afternoon depending on his work for the day. He finishes work by around 6:00 pm following which he comes home, has tea and takes a bath. Sometimes he works until 9:00 pm. He sleeps by 9:00 pm.
The patient has been chewing tobacco for around 10 years. 1 packet of tobacco lasts for 2 days.
He consumes alcohol on a regular basis since 30 years. He stopped for around 3 years and started again 6 months ago after the death of his daughter’s husband.
Bowel and bladder movements are regular.
TREATMENT HISTORY:-
He consumed medication for hypertension - Amlodipine and Atenolol for 20 days which he stopped around 10 days ago.
FAMILY HISTORY:-
No similar complaints in the family.
GENERAL EXAMINATION:-
Patient is conscious, cooperative, with slurred speech
Well oriented to time, place and person
Moderately built and moderately nourished.
Vitals :-
Temp - afebrile
BP - 140/80 mm Hg
Pulse rate - 78 bpm
Respiratory rate - 14 cycles per minute
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Oedema - absent
Motor Pathway -
Power:-
Rt UL - 3/5 Lt UL-5/5
Rt LL - 3/5 Lt LL-5/5
Tone:-
Rt UL - Increased
Lt UL- Normal
Rt LL- Increased
Lt LL- Normal
Reflexes:
Right Left
Biceps.
+++ ++
Triceps.
+++ ++
Supinator.
+++ ++
Knee.
+++ ++
Ankle.
+++ ++
Plantar:
Muted Flexion
Involuntary movements - absent
Fasciculations - absent
Sensory system -
Pain, temperature, crude touch, pressure sensations normal
Fine touch, vibration, proprioception normal
No abnormal sensory symptoms
Cerebellum -
Finger nose test normal, no dysdiadochokinesia, Rhomberg test could not be done
Autonomic nervous system - normal
JVP: Normal
INSPECTION:
Chest wall symmetrical
Pulsations not seen
PALPATION:
Apical impulse – normal
Pulsations – normal
Thrills absent
PERCUSSION:
No abnormal findings
AUSCULTATION:
INSPECTION:
PALPATION:
Abdomen is soft and non tender
No hepatomegaly
No splenomegaly
Kidneys not enlarged, no renal angle tenderness
No other palpable swellings
Hernial orifices normal
PERCUSSION:
Fluid Thrill/Shifting dullness/Puddle’s sign absent
AUSCULTATION:
INVESTIGATIONS
Anti HCV antibodies rapid - non reactive
HIV 1/2 rapid test - non reactive
Blood sugar random - 109 mg/dl
FBS - 114 mg/dl
Hemoglobin- 13.4 gm/dl
WBC-7,800 cells/cu mm
Neutrophils- 70%
Lymphocytes- 21%
Eosinophils- 01%
Monocytes- 8%
Basophils- 0
PCV- 40 vol%
MCV- 89.9 fl
MCH- 30.1 pg
MCHC- 33.5%
RBC count- 4.45 millions/cumm
Platelet counts- 3.01 lakhs/ cu mm
SMEAR:
RBC - normocytic normochromic
WBC - with in normal limits
Platelets - Adequate
Haemoparasites - no
CUE:
Colour - pale yellow
Appearance- clear
Reaction - acidic
Sp.gravity - 1.010
Albumin - trace
Sugar - nil
Bile salts - nil
Bile pigments - nil
Pus cells - 3-4 /HPF
Epithelial cells - 2-3/HPF
RBC s - nil
Crystals - nil
Casts - nil
Amorphous deposits - absent
LFTs:
Total bilirubin - 1.71 mg/dl
Direct bilirubin- 0.48 mg/dl
AST - 15 IU/L
ALT - 14 IU/L
Alkaline phosphatase - 149 IU/L
Total proteins - 6.3 g/dl
Albumin - 3.6 g/dl
A/G ratio - 1.36
Blood urea - 19 mg/dl
Serum creatinine - 1.1 mg/dl
Electrolytes
Sodium - 141 mEq/L
Potassium - 3.7 mEq/L
Chloride - 104 mEq/L
Calcium ionised - 1.02 mmol/L
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