19100006005 CASE PRESENTATIONS
LONG CASE :
Informant - Daughter in law
A 85 year old man from Narketpally, who used to work as a merchant in a local market, came with chief complaints of uprolling of eyes, frothing from mouth,and clenching of both fists at 3:30 pm on Saturday.
History of presenting illness
Patient was apparently asymptomatic on Saturday morning, had his lunch in the afternoon , sat on his bed, when he suddenly fell on the bed and developed clenching of his hands, uprolling of eyes and moving head to right side associated with frothing from mouth, lasting for about 3 - 4 minutes.
No history of involuntary micturition or defecation, deviation of mouth, no history of headache, nausea,vomitings prior to the event.
History of post ictal confusion present, patient was in drowsy state when brought to the hospital by the attenders.
Past history
Patient was apparently asymptomatic 10 years back, he is a chronic alcoholic and chronic smoker , drinks around 90-180 ml of whisky and around 500ml of toddy daily and smokes about 3 -4 packets of beedis per day.
He used to work as a merchant at a local market, but stopped going to work due to regular alcohol consumption, which interfered with his work, as he used to drink during daytime and used to fall on roads in intoxication, which made the family members to make him quit his work and stay at home. Since then, he stays at home , goes outside to drink alcohol ,chats with his friends and returns home.
Since the past 5-6 yrs, the attenders observed that he is forgetting things or events. He used to smoke beedis at home regularly which he personally keeps them at a particular place but forgets about it and asks family members sometimes. Forgets events like whether he had lunch or not sometimes.
Fails to identify his family members and close relatives who visit their house on and off.
The attenders attributed all these symptoms to his chronic alcoholism and were used to taking care of his daily activities, like guiding him to the bathroom, giving him clothes to dress.
He was once a well known person around his locality, settling any disputes or quarrels in his area, actively participating in local events. He gradually became less interested in those activities and usually stays at his home or goes to his daughter's house nearby.
3 years back , he attended a local wedding ceremony at night, had history of vomiting and involuntary defecation and micturition in the morning in his bed associated with uprolling of eyes and blinking, frothing from mouth and clenching of both fists, which lasted for around 10 -15 minutes, with post ictal confusion. Patient brought to hospital, necessary clinical examination and investigations were done. MRI brain showed
Left occipital old insult with glinting changes, age relate cerebral and cerebellum atrophy, small vessel ischemic changes and periventricular leukaraiosis.
He got discharged the next day with ? Tab.phenytoin 100mg once daily( attender not sure of name of the drug,said it was in a bottle with 100 tablets) and used to take once in the morning.
He was forced to quit alcohol by the attenders since then, but still drinks around 250 ml of toddy once a week and smokes atleast one packet of beedis per day.
He limited going out of his house( regularly goes to shop in front of his home to buy beedis) , or goes to his daughter's house which is few streets away. He used to have irritable behavior and used to get angry and raise his his hands on his family members.
Since the past 4-5 months, stopped taking antiepileptics ( due to cost issues and as he is seizure free for around 2 years).
He is not a known case of diabetes, hypertension, bronchial asthma,tuberculosis, coronary artery disease or thyroid disorders.
Personal history
He wakes up around 5 am ,goes to bathroom, roams around in the home,completes his bath, has to smoke his beedis, has his breakfast , again smokes, takes a nap for few hours. Has his lunch, sometimes goes outside to chat with his friends,sleeps for few hours, has his smoke, returns home, sleeps at around 9 pm after dinner. Easily wakes up during sleep on slight sounds at night.he stays with his wife, son, daughter in law and his grandkids.
Drug history
? Tab .Phenytoin 100mg od for 2 years
Family history
No history of similar complaints in the family.
Vitals
Temperature- afebrile
Pulse rate -82 bpm , regular
Blood Pressure -110/90 mmhg , right upper limb
Respiratory rate - 18 cpm
Spo2 - 99 %
GRBS - 116 mg/ dl
General examination
Patient is thin built and moderately nourished.
No Pallor,icterus ,cyanosis, clubbing, generalized lymphadenopathy
Central nervous system examination
Right handed person
Education - illiterate
Higher mental function examination
Consciousness- he is conscious, irritable
Orientation- not oriented to person, place or time.
Memory-
Immediate, recent and remote- pt not oriented and not co operative
Behavioral observation :
Physical appearance- thin built, moderately nourished
Emotional status- irritated on asking questions
Level of consciousness- conscious and irritable
Level of cooperation- not cooperative
Attention:
Ill sustained
Language:
-Spontaneous speech - absent
-Comprehension -
.Pointing commands --
.Yes or no response +
.Complex command --
-Repetition- absent
-Naming and word finding - not cooperative
-Reading and writing- illeterate.
Frontal lobe functions :
Attention ,working memory ,digit span- absent
Trail making test - couldn't be elicited
Sequencing test - couldn't be elicited
Verbal similarities and fluency test - couldn't be elicited
Conflicting instructions- couldn't be elicited
Judgement and insight - absent
Temporal lobe functions:
Memory
Recent memory,remote memory and historical facts, visual memory- not oriented
Parietal lobe functions:
Neglect
Inattention +
Decreased motivation +
Apraxia - couldn't be elicited
Constructional ability- couldn't be elicited
Calculation - absent
Right and left Orientation +
Finger agnosia and cortical sensations - couldn't be elicited.
Occipital lobe functions:
Prosopagnosia +
Unable to recognize familiar faces.
His MMSE SCORE is 3/30
Orientation 0
Registration 1
Attention and Calculation 0
Recall 0
Language 2
Cranial nerve examination:
1-olfactory:couldn't be elicited
2-visual acuity:couldn't be elicited
visual field:confrontation method
colour vision:couldn't be elicited
3,4,6
eyelids
position of eyeball at rest - central
extraocular movements - normal
pupil :normal in size,shape ,
2-visual acuity:couldn't be elicited
visual field:confrontation method
colour vision:couldn't be elicited
3,4,6
eyelids
position of eyeball at rest - central
extraocular movements - normal
pupil :normal in size,shape ,
direct and indirect light reflex- couldn't be elicited
5:sensory:touch
pain
temperature
motor: side to side jaw movement
reflexes: corneal
jaw jerk
5:sensory:touch
pain
temperature
motor: side to side jaw movement
reflexes: corneal
jaw jerk
Couldn't be elicited
7th-
motor-raise eyebrows
shuts eye.
orbicularis oculus - normal
orbicularis oris-
sensory: taste:couldn't be elicited
8th: rinnie's
Weber's -couldn't be elicited
9th,10th-
position of uvula: central
gag reflex present
11th- scm-
trapezius -couldn't be elicited
12th-
tongue: normal size,symmetry,
no deviation,tremor/fasiculation
motor:
motor:
Attitude of limbs:ul. ll:
bulk : not co operative for taking measurements. On inspection ,no wasting
tone: Right. left
upperlimb normal normal
lowerlimb normal normal
power:couldn't be elicited as pt is not obeying commands
1)Neck:. flexors:
extension:
2) shoulder:abduction:
adduction:
flexion:
extension:
3)elbow: flexion:
extension:
4) wrist : flexion:
extension:
5) Trunk: elevation of head
beevor's
abduction: gluteus
adduction:
6)knee: flexion: hamstrings
extrnsion: quadriceps
7) ankle: plantar flexion:
dorsiflexion:
Reflexes:
superficial
corneal
abdominal
plantar:
deep:
1)Neck:. flexors:
extension:
2) shoulder:abduction:
adduction:
flexion:
extension:
3)elbow: flexion:
extension:
4) wrist : flexion:
extension:
5) Trunk: elevation of head
beevor's
abduction: gluteus
adduction:
6)knee: flexion: hamstrings
extrnsion: quadriceps
7) ankle: plantar flexion:
dorsiflexion:
Reflexes:
superficial
corneal
abdominal
plantar:
deep:
jaw jerk
biceps
supinator
triceps
knee jerk
ankle jerk
Sensory:.
fine touch
joint position
vibration
crude touch
pain - flexing his limbs to pain
temperature
Romberg's test:couldn't be elicited
cerebellum:couldn't be elicited
finger nose
finger finger
knee heal
rebound phenomenon
tandem walking
Gait:
slow /rapid: slow
falling to sides: no
hand swing: present
turn: normal
autonomic nervous system: -
meningeal signs: -
Cardiovascular system :
S1 and s2 heard
No murmurs
Respiratory system :
Normal vesicular breath sounds heard
Abdomen:
Shape of abdomen -scaphoid
No palpable mass or tenderness on palpation
Provisional diagnosis
Tonic seizures
With dementia ?Vascular etiology /Alzheimer's disease
Smoker since 70 yrs
Alcoholic since 70 yrs
Investigations
Hemogram
Hb 12.2
Tlc 8,200
Platelets 1.7 lakhs
Serum electrolytes
Na+ 146
K+ 3.7
Cl- 99
Serum Urea 31 mg/dl
Serum creatinine 1.0 mg/dl
LFT
total bilirubin 0.6 mg/dl
Direct 0.2 mg/dl
AST 13 Iu/l
ALT 18 Iu/l
ALP 146 Iu/l
total protein 6.5 g/dl
Albumin 4 g/dl
Previous MRI brain 3 yrs back with perventricular leukaraiosis
Left occipital old insult with gliotic changes
Review of literature:
Algorithm for diagnosis of dementia
Differences between alzheimers disease and Vascular dementia
Based on above features points in favor of Alzheimer's disease in this patient are :
Gradual onset
Episodic memory loss
No focal neurological deficits
Points in favor of vascular dementia are :
Slow decline
Early appearance of executive dysfunction
White matter lesions in MRI - leukaraiosis
And small vessel ischemic changes
Seizures
Vascular risk factors - ?TIA, smoking, alcohol
Clinical appraisal :
Efficacy of donepezil in Early stage Alzheimers disease
Multicenter, randomized, double blinded, 24 week, placebo controlled study of patients with early stage alzheimers disease.
Objective
To evaluate the efficacy of donepezil in patients with early stage alzheimers disease
P - 153 patients with early stage alzheimers disease
I - 96 patients were given donepezil 5mg for first 6 weeks, with escalation to 10 mg
57 patients given placebo
C - primary efficacy measure was Alzheimer disease assessment scale- cognitive subspace.
Secondary efficacy measure was MMSE, Computerized memory battery test, patient global assessment scale and apathy scale.
These were compared between two groups at weeks 12 and 24 and at end point.
O - donepezil group showed more improvement than the placebo group.
Conclusion
Data shows significant treatment benefits of donepezil in early stage alzheimers disease, supporting the initiation of therapy to improve daily cognitive functioning
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SHORT CASE 1:
A 52 year old woman, home maker from Nalgonda, came with the chief complaints of swelling over left retroauricular and mandible region ,associated with pain since 1 week.
History of presenting illness
Patient was apparently asymptomatic 2 months back ,when she developed itchy skin lesions all over the body, initially small in size, gradually progressed to present size. Patient diagnosed with tinea corporis et cruris and treated with antifungals - itraconazole and luluconazole cream .
History of ulcer over lateral aspect of left leg 1 month back,associated with pain and swelling, used antibiotics and currently ulcer has healed.
History of swelling over left auricular and mandible region since 1 week
Associated with redness and pain during movement.no History of fever, trauma, went to a local hospital, found to have high sugars nd referred to our hospital for further management. Swelling diagnosed as acute parotitis and started on antibiotics.swelling has reduced over the past few days and pain subsided.
Past history
Patient was apparently asymptomatic 8 years back, had h/o fever for which she went to a local hospital and on routine investigations found to have high blood sugars and started on oral hypoglycemics (tab glimeperide 1mg +metfomin 1000mg) once daily. on regular follow up and was added metformin 500 mg at night 4 years back.
7 years back- had hernioplasty in view of incisions hernia( previous 4 LSCS in v/o ?delayed labour).
2 years back - pt had c/o giddiness for 1 month 1-2 times a day, lasting for few seconds, no postural variation, nausea or vomiting.,associated with headache. Diagnosed with hypertension and started on tab. Telmisartan 40 mg od.
Personal history
She is a home maker, wakes up at 7 am, does house chores( washing and cleaning dishes),prepares breakfast (idly,dosa), has breakfast with family members, takes break, prepares lunch, has h/o increased appetite since past 10 yrs, consumes around 2 cups of rice with vegetables, has non veg twice a week, takes nap for few hours ,has tea/coffee in the evening and has dinner (rice).
History of increased urine output since 5-6 years, has to get up 2-3 times at night, no h/o burning micturition.
Non smoker and occasional toddy drinker 500ml once in 2-3 months.
Menstrual history
Attained menarche at 13 years of age
Normal cycles, regular, 3/ 30, no clots
Attained menopause years back.
Vitals
Temperature - afebrile
Pulse rate - 86 beats per minute, regular
Respiratory rate - 16 cycles per minute
Bp - 140/90 mmhg
Spo2 -97%
Grbs- 259 mg%
General examination
Patient is conscious, coherent
Oriented to time ,place and person
Moderately built and nourished
Acanthosis nigricans +
Abdomen - obese
Multiple lesions with plaques with scaling present over neck , trunk ,upper and lower limbs.
No Pallor, icterus, cyanosis, clubbing , pedal edema.
Height - 160 cms
Weight- 88 kgs
BMI - 34.3
Waist circumference - 113 cm
Waist to hip ratio -0.89
Arm circumference - 31 cm
Serum triglycerides - 650 mg /dl
HbA1c - 15
Cardiovascular system examination
S1 and s2 heard
No murmurs
Apex beat felt at left 5 th intercoastal space lateral to mid clavicular line
Jvp normal
Respiratory system examination
Shape of chest - elliptical
All areas moving equally with respiration
No scars or sinuses ,
Normal vesicular breath sounds heard over all the areas
Abdomen examination
Shape of abdomen- distended ,obese
All quadrants moving accordingly with respiration
C - section scar present
No visible sinuses or engorged veins
Linear striae over Abdomen present
No local rise of temperature, tenderness on palpation
No palpable masses or organomegaly
Percussion - resonant note
Bowel sounds heard.
Cns examination
No focal neurological deficits
No sensory loss in all dermatomes
Fundus - no diabetic or Hypertensive retinopathy changes
Usg abdomen - grade 1 fatty liver
Diagnosis
Metabolic syndrome ( type 2 diabetes, hypertension, hypertriglycerdemia, obese )
With tenia corporis et cruris
And b/l parotitis (resolving)
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SHORT CASE 2 :
A 48 year old woman , daily laborer from nakrekal came with the chief complaints of abdominal distension since 6 months
Shortness of breath since 18 months
Pedal edema since 18 months
History of presenting illness
Patient was apparently asymptomatic 3 yrs back, had c/o giddiness for 1 week 2-3 episodes per day, each episode lasting for 1-2 minutes and relieved spontaneously on rest. She went to a local hospital, diagnosed as having hypertension and started on antihypertensive ( tablet not known) , used them for 3 months and stopped as bp became
normal and as the complaints subsided, she was not on follow up.
History of decreased appetite, nausea , vomitings -non projectile , non bilious, food as content 18 months back
History of pedal edema since 18 months , which is bilateral , pitting type, painless, initially upto ankles, gradually progressed upto knees, no aggravating or relieving factors associated with decreased urine output and facial puffiness. Shortness of breath since 18 months, initially grade 2 gradually progressedto grade 3, aggravated on work , relieved on taking rest.
She went to a local hospital where she was told to have kidney failure and referred to higher center for dialysis.
She visited our hospital where she was diagnosed with Heart failure with preserved ejection fraction and renal failure and started on dialysis.
Since 6months, pt complaining of abdominal distension, gradually progressed to present size, with increased shortness of breath on lying down, dyspepsia and decreased appetite .no aggravating factors, symptomatic relief after dialysis. Ascitic fluid paracentesis done with high SAAG transudative picture.
Past history
Hypertensive since 3 years
History of 1 LSCS 25 years back
Non smoker ,toddy drinker 2-3 times per week
Vitals
Temperature afebrile
Pulse rate 76 beats per minute
Respiratory rate 20 cycles per minute
Blood Pressure 150/80 mmhg
Spo2 -96 %
General examination
Patient is conscious, coherent and coperative
Pallor +
No icterus , cyanosis ,clubbing, generalized lymphadenopathy.
Pitting type of pedal edema present upto knees bilateral
A v Fistula over right forearm present
ABDOMEN EXAMINATION:
Inspection
Abdomen distended , tense, flanks full
Umbilicus central in position ,everted
Longitudinal striae present over lower Abdomen
Longitudinal c section scar present below the umbilicus extending upto public tubercle .
No visible sinuses
Engorged veins present
Palpation
No local rise of temperature
No tenderness
No mass
Liver and spleen not palpable
Percussion
Shifting Dullness absent
Fluid Thrill present
Auscultation
Bowel sounds heard
Cardiovascular system examination
Shape of chest elliptical
No scars or sinuses
No precordial pulsations
Jvp elevated
Apex beat felt at 6 th intercoastal space lateral to mid clavicular line
S1 s2 heard
No murmurs
Respiratory system examination
Respiratory movements equal on both sides
Decreased breath sounds at right infra axillary area
Normal vesicular breath sounds heard
CNS examination
No focal neurological deficits
Investigations
Hb - 8.6
Tlc _ 5500
Plt -1.7 lakhs
Serum Urea 90 mg/dl
Creatinine 5.6 mg/dl
Total bilirubin- 1.0
Direct - 0.4
AST -40
ALT --38
ALP- 120
Total protein- 5.5
Albumin 3.0
Diagnosis
Ascites secondary to heart failure with preserved ejection fraction
Cardiorenal syndrome type 3 on maintenance hemodialysis
Hypertension since 3 years
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