20100006006 CASE PRESENTATION

 LONG CASE 


Chief compliants

1) Slowness of movements since 1 year .

2) Involuntary movements of the Left upper limb.

3) Slowness in speech since 1 year.


History of present illness

60 year old female,who is a mother of 3 children (  1 son and 2 daughters ), labour by occupation ( goes to agriculture field ) was apparently asymptomatic 1 year back, then developed Slowness of movements which was insidious onset, gradually progressive not associated with any weakness associated with difficulty in initiation of movement and difficulty in day to day activities .The difficulty was in such a way that she could not even comb the hair, mix the food and bathing.
History Involuntary movements of the left upper limb since 1 year , occuring at rest ,aggravated by emotional stress and disappeared during sleep and movement.

History of associated postural changes .

No History of sensory disturbances 

No History of anosmia.

History of sleep disturbances- present 

No History of Genito urinary and Gastro intestinal disturbances.

No History of Dysphagia 

No History of fever , convulsions and coma

No History of head injury

No History of yellowish discoloration of eyes

No History of usage of any antipsychotic drugs.

Family History: 

No Significant family History

Personal history: 

Mixed diet 
Normal bowel and bladder
Sleep: 

Past history

No history of similar complaints in the past .
No history of Diabetes, Hypertension, Cerebrovascular disease, Cardiovascular disease .

General Examination: 

Patient is conscious and Co operative.

Facies

Infrequent blink with Starring look.
Loss of facial expression.

No pallor, icterus, Cyanosis, clubbing,lymphadenopathy, edema

Pulse

BP: supine - 110/70mmhg 
       PR: 80bpm
       Standing - 100/70 mmhg.
       PR: 90 bpm

Posture : stopped posture.

Neurological examination: 

1. HIGHER MENTAL FUNCTIONS:
a. Consciousness-   Normal
b. Orientation to time, place and person- present.
c. Speech and language -slow speech.
d. Memory -Normal
e. Delusions, hallucinations- No
f. Emotional lability
g. MMSE score
I. Orientation
1.date, day, mönth, season, year -4
2. floor, hospital. District, state, country- (5) 
II. Registration
Name three objects taking one second for each obiect. Ask him to repeat the same
Repeat till he remembers (3) 
III. Attention and Calculation 
Serial 7's 5 times - 4 points.
IV. Recall
Recall the three objects (3) 
V. Language
I. Name 2 obiects (2) 
2. Repeat a sentence (1) 
3. Follow a 3 stage command (3)
4. Reading "close your eyes"- Not done.
5. Writing a sentence - Cannot write.
6. Copy a design (1)

TOTAL SCORE- 26/30

2] CRANIAL NERVES.                               
I) Sense of smell      - Normal on both sides.                               
II) On Right side - No perception of light 
On left side - Visual acuity, colour vision - Normal.                                      
III,IV,VI)
i) Extra-ocular movements  - Normal in both eyes .                    
ii) Pupil - Size - 2-3 mm in both eyes.                                          
ili) Direct Light Reflex - Sluggish in right eye 
     Constriction of pupil- left eye.                      
iv) Consensual Light Reflex- Absent in left eye.                      
v) Accommodation Reflex - Absent in right eye,                          
vi) Ptosis    - absent                                              vil) Nystagmus    - absent                 
V) 
i) Sensory -over face and buccal mucosa -presen 
il) Motor - masseter, temporalis, pterygoids- normal 
iii) Reflex a.Corneal Reflex  - present in both eyes.                              
b. Conjunctival Reflex  - present in both eyes.  C.Jaw jerk - absent                                                VII)
i) Motor - intact on both sides                            il) Sensory -
Taste of anterior 2/3rds of
tongue- present.
Sensation over tragus                                
iii) Reflex -
Corneal- present                                                    Conjunctival- present.                                          
8)
i) Rinnes Test - AC more than BC                        ii) Webers Test- unable to perceive the vibrations when tuning fork - kept on fore head.
IX,X)
i) Uvula, Palatal arches, and movements- Normal 
¡¡)Gag reflex - Present                                        
iii) Palatal reflex- Present                       
XI)
i) trapezius- able to perform .                              ¡¡)sternocleidomastoid -slight difficulty in turning                
XII)
¡)Tone-Normal                                                 
¡¡)wasting- No                                                 
iii) Fibrillation-No                                                   iv) Movements - normal.

3] Motor system 
I- BULK
a. Inspection   - Normal                                           
b. Palpation     - Normal                                           
c. Measurements     
Upper limb- MAC -30 cm on both sides.
Lower limb-MLC -  31cm on both sides                        
II - TONE
a.Upper limbs- Fluctuant rigidity in upper limbs - Cog wheeling type .
b. Lower limbs- rigidity experienced throughout movement - Lead pipe type.
III - POWER
a. Neck muscles- 5/5 
b. Upper limbs
i)Shoulder
Flexion-Extension-5/5
Lateral Rotation-Medial Rotation-5/5
Abduction -Adduction-5/5
ii)Elbow
Flexion-Extension-5/5
iii)Wrist
Dorsi flexion-Palmar flexion-5/5
Abduction-Adduction-5/5
Pronation-Supination-5/5
iv)small muscles of hand-5/5
V)Hand grip- Normal.

с.Lower limbs
i)Hip
Flexion-Extension-5/5
Abduction-Adduction-5/5
Lateral Rotation-Medial Rotation-5/5
ii)Knee
Flexion-Extension-5/5
iii)Ankle-
Dorsi flexion-Plantar flexion-5/5
Inversion-Eversion-5/5

IV -REFLEXES
A. SUPERFICIAL REFLEXES( Both sides ) 
1. Corneal- Present 
2. Conjunctival- Present.
4. Palatal Reflex-present 
5. Abdominal Reflex-present 
5. Plantar Reflex- Negative.

B. DEEP TENDON REFLEXES( Both sides ) 
1. Jaw jerk- Absent 
4. Biceps jerk- +2 
5. Triceps jerk-+2
6. Supinator jerk-+2
7. Finger flexion reflex- no response.
8. Knee jerk-+2
9. Ankle jerk-+2
10. Clonus- Absent 

VI GAIT- Video 


VIl - INVOLUNTARY MOVEMENTS- Absent 
A - Athetosis, Asterexis
B- Ballismus
C - Chorea
D- Dystonia
E - Essential tremors
F -Fasciculations
M - Myoclonus

4]SENSORY SYSTEM
TEST
I - SPINOTHALAMIC( Both sides )
1. Crude touch- Normal 
2. Pain- Normal 
3. Temperature- Normal 

II - POSTERIOR COLUMN
1. Fine touch- Normal 
2. Vibration- Normal 
3. Proprioception - Normal
4. Romberg's sign- negative

III - CORTICAL( both sides ) 

1. Tactile localisation- present
2. Graphaesthesia- Present 
3. Stereognosis- present 

5]CEREBELLAR SIGNS
 Coordination( on both sides ) 
a. Upper Limbs - Finger Nose test, Finger Finger Nose test, Drawing a circle,
Putting a dot in the centre of the circle ~ Present 
b. Lower Limbs - Heel Knee test
c. Dysdiadokokinesia- Absent

6. AUTONOMIC NERVOUS SYSTEM
Postural Hypotension
Resting tachycardia
Abnormal sweating

7. SIGNS OF MENINGEAL IRRITATION
Neck stiffiness- Absent 
Kemig's sign-Absent 
Brudzinski's sign-Absent 

Examination of other systems: 

 CARDIOVASCULAR SYSTEM:
JVP- Not raised ,Apex normally placed, no Palpable P2, Heart sounds - normal, No thrills/murmurs

RESPIRATORY SYSTEM:
Chest symmetrical, No paradoxical movements, Normal vesicular breath sounds heard,
No abnormal/added sound

ABDOMEN:
Abdomen is soft, No organomegaly, No ascites.

Test for extensor digitorum brevis
Rinnes test
Tibialais posterior.
Ilio psoas
Interossei muscle testing

Lumbricals

Adductor pollicis 
Testing for pain:


DIAGNOSIS
INVESTIGATIONS: 

RBS- 91mg/dl
Blood urea- 28mg/dl
Serum creatinine - 0.7mg/dl

CUE
Colour: pale yellow
Appearance: Clear
Albumin NIL
Sugar NIL
Bile salts and pigments NIL
Pus cells: 2-3
Epithelial cells: 2-3
RBC NIL
Crystals, casts NIL
Amorphous deposits NIL

HEMOGRAM
HB: 13.2
TLC: 7700
N/L/E/M: 53/33/4/10
PCV: 40.3
MCV: 82.3
MCB: 27.1
MCHC: 32.8
RBC: 4.87
PLT: 3.5

LFT
TB: 1
DB: 0.2
AST: 17
ALT: 9
ALP: 148
TP: 7.4
ALBUMIN: 4.0
A/G: 1.2

HIV- negative
HBsAg- negative
HCV- negative

ECG: 
CXR- PA 
TREATMENT: 

1) Tab Syndopa ( levodopa 100mg+ Carbidopa 25 mg) PO/OD

----------------------------------------------------------------------------------------------------------------

SHORT CASE I

 

Chief complaints

Multiple joint pains since 7 years.

History of present illness : 

Patient was a Taylor in the medical institute, her daily routine was to stitch the clothes with the help of machine from 9am to 4 pm in the medical institute.

She was apparently normal 7 years back , then developed pain in the right proximal interphalangeal joints association with stiffness in the early morning for about 1 hour and which gradually relieved after 2 hours of getting from the bed.Her early morning stiffness was severe in such a way that she used to take the help of his husband while getting up from the bed .
After few days she developed pain in the left proximal interphalangeal joints, which gradually progressed to wrist joint , elbow , ankle and meta tarsophalangeal joint.

No history of hair loss, oral ulcerations ,rash over the face.

No history of thickening of the skin.

No history of cough and shortness of breath.


Past history: 

No significant past history.

Family History: 

No significant family history.

General examination: 

Examination:

Pulse Rate: 80 beats per minute

Blood Pressure: 100/60 mmhg

Respiratory Rate: 22 cycles per minute

Temperature: 98.6 F

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema 

General Examination:

Hair:

Normal hair distribution.

Eyes:

No erythema noted on conjunctiva .

Oral Cavity:

No mucosal ulcers 

Nails:

No nail pitting, onycholysis, onychodystrophy

Skin:

No rash , ulcers over the skin, scaly lesions, dryness of skin, thickening of skin, no rash on sun exposed areas of the skin, no subcutaneous nodules.

Spine:

No spinal deformity

Musculoskeletal examination: ( positive findings) 

Tenderness noted in the MCP joints of both fingers

Right Little finger: Boutonniere deformity
Left little finger: Swan neck deformity.


Boutonniere deformity of little finger
 Swan neck deformity of left finger.

Investigations: 

X ray both hands including wrist joints: 


X ray both feet : 

Chest x ray : 
Bilateral reticulonodular opacities noted in both lungs 

Other systems:

Respiratory System: No abnormality detected
Cardiovascular System: No abnormality detected
Abdomen: No abnormalities detected
Nervous System: No abnormalities detected


Investigations: 

CUE
ALBUMIN - NIL 
SUGAR - NIL
PUS CELLS -NIL
EPITHELIAL CELLS - NIL 

CBP
HB - 12.0 
TLC - 9,000
MCV - 82.1 
PLATELETS - 3.02 LAKHS 
NCNC 

RBS - 106 

LFT
TB - 0.60 
DB - 0.19 
AST - 15 
ALT - 212 
ALP - 136 
TP - 6.4 

RFT
UREA - 14 
CREATININE - 0.8
URIC ACID - 3.8 
Ca+ - 9.4 
Phosphate - 2.6 
Na + - 143 
K+ - 3.7 
Cl - 105

Other investigations

C reactive protein - 2.4mg/dl.( Reference range -0.6mg/dl)

RA factor - Positive (96IU/ML) .

ESR - 33mm/1st hour.

Provisional Diagnosis:

Multiple symmetrical polyarthritis with chronic duration of around 7 years and with signs of inflammation, involving PIP joints and MCP joints with sparing of DIP joints - Rheumatoid Arthitis
with no other system involvement. 

Treatment: 

1) Tab Methotrexate 10 mg/ PO/weekly once .

2) Tab Folic acid 5mg / PO/weekly once.

3) Tab HCQ( Hydroxy chloroquine 200mg)/PO/ Once daily.

4) Tab Naproxen 250mg /PO/SOS.
 
----------------------------------------------------------------------------------------------------------------
 SHORT CASE II

Chief compliants: 

Absent Menstrual cycle 6 months back.

History of present illness : 

Patient was apparently asymptomatic 6 months back, then she developed absent Menstrual cycles not associated with any pain abdomen and vomtings and then she went to the gynecology OPD and on routine evaluation , the ultrasound abdomen showed altered renal echotexture and Urine analysis showed Proteinuria and she was referred to general medicine department for further work up.

No history of any rash over the malar areas, ulcers in the mouth and pain in the joints.

No history of any hematuria , throat pain, skin rashes.

No history of fever ,pain abdomen , cold etc.

No history of any pedal edema , shortness of breath and decreased urine output

No history of any loss of appetite, dryness of skin and vomtings .

Past history: 

No history of similar complaints in the past.

History of seizures at around 2 years of age.

GENERAL EXAMINATION:

No pallor ,icterus,clubbing,cyanosis,lymphadenopathy.
Pedal edema.

SYSTEMIC EXAMINATION:

BP: 100/80
PR: 70BPM
CVS:S1S2+
RS; BAE+
P/A: SOFT,NON TENDER

Clinical images : 





Investigations: 

LFT -
TB -0.7 
DB - 0.12 
AST - 10 
ALT - 08 
ALP - 238 
TP - 6.2 
ALB - 4.19 

RFT 
UREA - 43 
CREATININE - 3.7 
URIC ACID - 7.8 
Ca + - 9.6 
Phosphate - 3.7 
Na - 145 
K+ - 4.1 
Cl- 103 

CUE
ALBUMIN - 3+ 
RBC - 1-2 
Crystals - 2+ 
CASTS - NIL 
PUS CELLS - NIL 

CBP
HB - 9.8 
TLC - 8,600 
PCV - 29.4 
RBC - 3.51 MILLION
PLTS - 1.66 LAKHS

24 hour urinary protein was 900mg/ day.

Renal biopsy: 
Electron microscopy: 




Treatment: 

1) Tab Mycophenolate mofetil 360mg /PO/TID.

2) Tab Minipress XL /PO/OD 

3) Tab Bisoprolol 2.5mg /PO/OD .

Critical appraisal: 

https://pubmed.ncbi.nlm.nih.gov/36745456/


P -The role of mycophenolate mofetil (MMF) in management of immunoglobulin A nephropathy (IgAN)

I-total of 170 participants were randomized in a 1:1 ratio to receive MMF (initially, 1.5 g/d for 12 months, maintained at 0.75-1.0 g for at least 6 months) plus SC or SC alone.

C- During a 3-month run-in period, 238 patients received optimized supportive care (SC), including losartan

O-This study found that addition of MMF to SC compared with SC alone significantly reduced risk of disease progression among patients with progressive IgAN.

 

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