Medicine

Hello all, iam an Intern, and this is a case history of one of our patient's who got admitted . This is to complete my log book as  a part of internship duty

Case report
A 23 yr old male patient has   complaints of weakness of bilateral lower limbs since 5 days
complaints of tingling and numbness 
h/o vomitings 5days back 3-4 episodes non projectile non bilious food particles is content.
when he got up for urination,suddenly he had a fall and got up with the help of father.
gluteal abscess since 5months (operated 5 months back) 
scrotal abscess since 20 days(incision and drainage 10 days back)

PAST HISTORY 
no similar complaints in past 
h/o multiple sexual partners
auto driver( high risk behaviour)
not a known case of HTN/DM/ASTHMA/CAD

General examination: 
Pallor absent
Icterus absent
No cyanosis clubbing lymphademopathy,Edema
Afebrile
Gluteal abscess post drainage

Bp 120/80 mm hg
Pr 80 bpm
spo2 98%
Cvs s1 s2 hears no murmurs
Rs bae + nvbs hears
P/a soft, non tender
Cns conscious
speech-normal
cranial nerves intact.
MOTOR SYSTEM 
                         Right.         Left
Bulk:               normal.      Normal
Tone: ul.        normal.       Normal
           LL.       hypotonia    hypotonia
Power          rt.          lt
         ul.        5/5.      5/5
         LL.       2/5.      0/5
Reflexes.  
   Superficial reflexes
                       Right.           Left
Corneal.        P                   P
Conjunctival P.                  P
Abdominal.   P.                  P
Plantar          Extensor   Extensor
    Deep tendon reflexes 
                     Right.             Left
Biceps.        2+                  1+
Triceps.       2+                   1+
Supinator.    3+                   2+
Knee             3+                  2+
Ankle.           3+                  2+
jaw jerk.        1+.                1+
ankle clonus present.     absent
Primitive reflex -absent
Involuntary movements - absent 
 
SENSORY SYSTEM - normal

CEREBELLUM
titubation - absent
Nystagmus- absent
Intensional tremors - absent
Pendular knee jerk - absent 
Coordination test -normal

MENINGIAL SIGNS
Neck stiffness - negative
Kernigns sign - negative
Brudzinkis sign - negative


INVESTIGATIONS
HBS AG: negative
ANTIHCV ANTIBODIES: nonreactive
HIV : non reactive
HEMOGRAM : 
HB        15.5gm/dl
Platelets 2.23 lakhs/cumm
TLC         9600cells/cumm
Lymphocytes 15%         
LFT
TO.BIL.       0.82mg/dl
DI.BIL.          0.21gm/dl
SGOT.            80IU/LIT
SGPT.             10IU/LIT
ALK.PH.            192IU/LIT
TO.PRO.                7.5gm/dl
ALB.                        4gm/dl
A/G RATIO.           1.19
RFT
UREA.                  16mg/dl
CREATININE.      0.6mg/dl
URIC ACID           3.7mg/dl
CALCIUM.            9.4mg/dl
PHOS.                  4.6mg/dl
SODIUM.              136meq/lit
K+.                         3.9meq/lit
CL-.                       102 meq/lit
ESR 45 mm/1st hr
RBS 99 mg/dl
X ray images

Mri images of the above patient are as below


There is significant enhancement which represents meningeal enhancement or exudates and following lesions in mri with multiple nodules in pulmonary apices  suggest of pulmonary kochs and disseminated tuberculosis.

Diagnosis:paraparesis with L4,L5infective spondylodiscitis with left psoas abscess with ring enhancing lesions in right and left cerebral hemispheres with healing ulcer in right gluteal region secondary to drained gluteal abscess with pyocele left side operated ( 10 days back)

TREATMENT :
T.ATT 3 tabs/day fdc
T.Benadon 40mg/od
T.pregabalin 75mg/po/h/s
OINT.MEGAHEAL FOR LOCAL APPLICATION
SITZ BATH WITH BETADINE TID
FREQUENT CHANGE OF POSITION

Procedure
I have seen 2DEcho done to a heart failure patient secondary to viral myocarditis
Bells palsy is a LMN lesion  of facial nerve complaints are deviation of mouth to opposite side,loss of nasolabial fold on same side,unable to close to the eyes, loss of taste ,
Treatment : prednisolone 
                      Antivirals like acyclovir
                     Eye drops and eye patch
                     Physiotherapy


Comments

  1. caregiver7careseekerMay 14, 2020 at 9:08 PM



    This link that you shared is not clickable in your blog.

    "I have seen 2DEcho done to a heart failure patient secondary to viral myocarditis"


    https://drive.google.com/file/d/1VAujxtx3cDhpt39_lXGL0UlEi-RUgO_-/view?usp=drivesdk

    Why not upload it to youtube or at least make the link clickable in your blog. You have to select the link in your blog and then click on the icon marked "link" near the top buttons where you click to publish.

    ReplyDelete
  2. caregiver7careseekerMay 14, 2020 at 9:09 PM

    Also what is the evidence for steroids or acyclovir in Bell's palsy

    ReplyDelete
  3. RishikMay 20, 2020 at 6:12 AM

    Mam ,
    Is there any history of Trauma??
    I mean Head trauma or Lower back spine injury??
    Is there any past history of TB??

    ReplyDelete
    Replies
    1. VaishnaviMay 20, 2020 at 10:28 AM

      Hii,
      No there is no history of trauma and now he is diagnosed with tb,he was not diagnosed before because he had no exact tb symptoms

      Delete
    2. RishikMay 20, 2020 at 10:41 AM

      Tq Mam
      Does he complaints of any pain or tenderness and any limitations of movements pertaining to spine??

      Delete
    3. VaishnaviMay 21, 2020 at 5:32 AM

      There is no pain or tenderness because it could be a cold abscess and no limitations as such pertaining to Spine

      Delete
  4. avinash roll.no.01May 21, 2020 at 12:36 PM

    Mam what type of MRI it is? I think Dw-MRI (Diffusion weighted MRI )is useful in this case so as to detect the location of acute infarcts because he has a history of sudden fall i.e stroke like symptoms.

    *MR - spectroscopy may also be useful to detect which type of lesion for example tuberculoma,meningioma,or any other tumour
    * mam.. whether the abcess or external scrapings of gluteal abcess sent for culture microscopy?
    * Is there any test to detect HIV within 6months of entry of infection ,because he had history of multiple sexual partners? And also because TB is mostly commonly associated in hiv patients.
    Thank you

    ReplyDelete
    Replies
    1. VaishnaviMay 22, 2020 at 11:27 AM

      Yes evacuated pus is sent for culture
      Hiv can be diagnosed by rapid tests
      But his serology was negative

      Delete
  5. avinash roll.no.01May 21, 2020 at 2:55 PM

    https://avinashrollnumber1.blogspot.com/2020/05/23yr-old-male-with-paraparesis.html

    My suggestions and review of this case!!

    ReplyDelete
  6. RishikMay 22, 2020 at 1:26 AM

    http://rishik37.blogspot.com/2020/05/gm-elog-case-2.html

    My Review of this case.

    ReplyDelete
  7. Divya MahapatraMay 22, 2020 at 9:41 AM

    Hello Maam
    i have a few doubts regarding this case which are as follows:

    1)What's the reason for his elevated liver enzyme levels and esr level?

    2)what about his family history, travel history and diet history?

    3)can we assume that xray finding pointing towards spondylodiscitis may have some relation to TB (potts disease maybe??)

    ReplyDelete
    Replies
    1. VaishnaviMay 23, 2020 at 7:19 PM

      Esr will be raised in tb
      Liver enzymes are raised that can be due to tb affecting liver
      No significant family history
      Yea it can be Potts disease

      Delete
  8. Divya MahapatraMay 22, 2020 at 10:27 AM

    and maam he has ankle clonus in right LL - doesn't that mean he has UMN LESION
    but hyporeflexia and hypotonia point toward LMN LESION?

    ReplyDelete
    Replies
    1. VaishnaviMay 23, 2020 at 7:15 PM

      Yes patient had ankle clonus and hyperreflexia in right lowerlimb which means that he had umn lesion and tone can be hypotonia in some cases even in umn lesion.find out in which conditions do hypotonia present in umn lesion?

      Delete
    2. RishikMay 23, 2020 at 7:47 PM

      UMN lesions with Neuronal Shock can have hyper reflexia with Hypotonia.

      Delete
    3. VaishnaviMay 23, 2020 at 9:55 PM

      What is neuronal shock? In which conditions do this happen?

      Delete
    4. RishikMay 24, 2020 at 12:35 AM

      This comment has been removed by the author.

      Delete
    5. RishikMay 24, 2020 at 12:37 AM

      The initial period of “hypotonia” after upper motor neuron injury is called spinal shock, and reflects the decreased activity of spinal circuits suddenly deprived of input from the motor cortex and brainstem.

      https://www.ncbi.nlm.nih.gov/books/NBK10898/

      Delete
  9. sai anudeep Modukuru r.no 98May 23, 2020 at 12:22 AM

    Ma'am is there any behavioral changes in the patient

    ReplyDelete
  10. sai anudeep Modukuru r.no 98May 24, 2020 at 7:10 AM

    My reviews of this case http://gm-elogbook-anudeep-98.blogspot.com/2020/05/gm-e-log-case-2.html

    ReplyDelete
  11. P.Nikhitha-130 (final year student)May 26, 2020 at 10:53 PM

    Why did SGOT and alk.ph levels elevated in this case? Any suspicion of Hepatic tuberculosis? Is Liver biopsy done in this patient?

    ReplyDelete
  12. Vihar ReddyMay 29, 2020 at 12:18 PM

    Ma'am why havent we considered syphilis as a differential

    I know that he has been diagnosed with tuberculosis and that explains all of his symptoms I am just asking so that I can review if my thinking and choosing differentials is in the correct route

    ReplyDelete

Post a Comment

Popular posts from this blog

Medicine intern

Hello everyone..  I am an intern in Medicine and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties from my cases, the procedures that I do as well as the theory questions and discussion that I engage in.  Case report  He has slurring of speech since 3 days and weaknesses of right lower limb since 4 days. while passing stools all of a sudden unable to getup weakness of rt lower limb 4 days back. h/o involuntary micturition no involuntary movements. no drooling of saliva no loss of consciousness no deviation of mouth no chest pain ,sob, palpitations,fever,cough PAST HISTORY  hypertension since 3 years (2017) used medication for 1.1/2 year no h/o DM ,CAD, epilepsy ? CVA 2yrs back right sided hemiparesis was diagnosed as hypertension also  hypertension medication &CVA stopped since 6 months      General examination: Pallor absent Icterus absent No cyanosis clubbing lymphademopathy,
Read more

35 yr old female

Image
Case report A 35yr old female presented with complaints of vomitings 3 episodes 6 days back followed by altered sensorium . no h/o trauma  no involuntary movements  no h/o deviation of mouth  no h/o fever,cough,chest pain,tremors,orthopnea,pnd no h/o use of anticoagulants,oral contraceptive pills  past history: h/o intermittent headache. known case of tb 4yrs back ,took ATT for 6 months. no h/o HTN,DM,CVA,CAD,SIZURES. surgical history negative. General examination: Pallor present  Icterus negative No cyanosis clubbing lymphademopathy,Edema. Mild dehydration and malnutrition present .Doll's eye postive Bp 100/60 mmhg Pr 110 bpm spo2 96% temp 102F RR 20cpm Grbs 119 gm/dl Cvs s1 s2 hears no murmurs Rs bae + nvbs hears P/a soft ,nontender,bowels sound heard, Cns  HMF- patient unconscious         stuporous speech- no response MMSE- not elicited cranial nerves-1st not elicited 2nd not elicited                                              rt         lf 3rd,4th,6th                      pup
Read more