Long case 8
AGE : 45 yrs
SEX : male
OCCUPATION : farmer
RESIDENCE : Nandikotkur
C/o Weakness of lower limbs for the last 8 days
C/o Weakness of upper limbs for the last 7 days
Patient was apparently normal 8 days back, present complaints started as weakness of both lower
limbs,initially he noticed weakness in the lower limbs in the form of unable to get from bed without
support ,difficulty in standing from squatting position ,difficulty in climbing stairs,difficulty in gripping
chappals, patient was used to carried by 2 persons to attend routine activities, later on he was bed
ridden in a span of 3 days as the weakness progressed.
C/o weakness of both upper limbs since 7 days in the form of difficulty in holding objects, mixing food,
buttoning & unbuttoning
difficulty in comb hair, taking food to mouth, raising arms above the head.
Unable to sit from lying down position, unable to rollover in bed from side to side.
No c/o bladder and bowel disturbences
No h/o involuntary movements and fasiculations
No h/o withdrawal of limbs
No h/o thinning of limbs
Able to feel cloths over body and able to feel hot & cold sensation while bathing
no h/o diurnal variation of weakness, wash basin attacks, difficulty in walking narrow passages.
Able to feel the ground normally. No c/o cotton wool sensation
No h/o shock like sensation on bending neck/ tight band like sensation over chest
No h/o excessive sweating/loss of sweating/postural fall/ syncope
No h/o trauma/recent vaccination/dog bite/ear discharge
No h/o rash/fever/arthralgias
He is able to perceive smell normally.
No c/o blurring of vision.
Able see colors normally.
No c/o double vision, no c/o drooping of eye lids.
No c/o difficulty in chewing food.
Able to sense hot and cold sensations over the face normally.
No c/o drooling of saliva, deviation of angle of mouth. No c/o taste disturbances.
No c/o decreased hearing or tinnitus or vertigo.
No c/o difficulty in swallowing food or nasal regurgitation of food /liquids.
No c/o speech disturbances.
Able to shrug shoulders, able to turn head side to side.
No c/o difficulty in making food bolus in mouth.
No c/o bowel and bladder disturbances
No c/o giddiness on getting up in the morning.
No c/o headache, seizures, neck stiffness, altered sensorium.
PAST H/o:
No h/o similar complaints in the past.
No h/o tuberculosis, asthma, IHD, CVA, epilepsy.
Not a known hypertensive or diabetic.
No h/o previous surgeries.
No h/o chemotherapy / radiotherapy .
PERSONAL H/O:
Takes mixed diet. Married, has 2 sons.
No c/o sleep disturbances.
No habit of smoking or alcoholism.
FAMILY H/O:
Born out of non consanguineous marriage.
3rd in birth order.
No h/o similar complaints in family members.
Treatment h/o:
Admitted in ggh Kurnool, taking treatment
Summary
General examination
Patient is conscious/coherent and oriented to date time and place
Moderately built and nourished
No pallor, jaundice, cyanosis,
clubbing , pedal edema and lymphadenopathy.
No markers of neurocutaneous syndromes, connective tissue disorders, TB, HIV and peripheral nerve
thickening.
VITAL DATA
Pulse- 90/min, regular,
normal in volume and
character ,no radio-radial
and radio femoral delay,
vessel wall thickening.
B.P-130/90 in right upper limb in supine position
R.R-16 cycles/min
Temperature – 37.5 degree centigrade
CNS examination
Right handed person.
Higher mental functions: MMSE- 28/30.
Appearance and behaviour of patient is normal.
Conscious, coherent, cooperative.
Oriented to time, place, person.
Memory immediate, recent, remote – normal.
Speech : Normal.
Language : Comprehension intact
fluency -Intact.
Repetition - normal
Naming - intact
Reading – intact
Writing – impaired due to weakness of hand.
No delusions, hallucinations, emotional lability.
CRANIAL NERVE EXAMINATION
Motor system-
Attitude- patient is lying on bed in supine positon with arms adducted, extended at the elbow,
supinated, both legs adducted, extended at hip, knee joints, externally rotated foot.
• No Wasting of muscles of hand , forearm, arm are seen on both sides.
Sensory system examination-
Cortical sensations: Two point discrimination, graphaesthesia, tactile localisation, stereognosis-normal
on both sides.
Signs of cerebellum consistent with weakness.
No meningeal signs
No signs of autonomic dysfunction.
Spine and cranium – normal.
Other system examination :
Cardiovascular system:
S1 ,S2 normal in all areas ,no murmurs/ thrills.
Respiratory system :
bilateral air entry +, normal vesicular breath sounds, no adventitious sounds.
Gastrointestinal system : abdomen soft, no organomegaly, no ascites
Short case-1
A 52 yr, male came with complaints of
Abdominal distension since 6 months
Bilateral pedal edema since 30 days.
Yellowish discoloration of eyes since 30 days
One episode of hematemesis 5 days back.
General examination:
Patient is conscious & coherent
Patient is moderately built & moderately nourished.
Pallor +, icterus+, bilateral pitting pedal edema up to thighs ,
No cyanosis, no clubbing, no lymphadenopathy.
No scratch marks, tattoo marks.
No markers of TB, HIV, connective tissue disease.
Ht- 165 cms, wt- 55 kgs. BMI- 26
Peripheral stigmata of chronic liver disease:
Icterus+, alopecia+,
Bilateral parotid enlargement +,
Spider naevi (-),
Scanty axillary & pubic hair
Gynecomastia, testicular atrophy (-),
Hepatic foetor (-),
Palmar erythema +, duputren’s contracture (-),
Asterixis (-) .
Vital data:
Pulse : 98/min ,regular , normal in volume and character and condition of the vessel wall,
no radio-radial or radio-femoral delay and all peripheral pulses are equally felt.
Blood pressure: 100/70 mm hg in right upper limb in supine position
Resp .rate: 16 cycles/min ,
abdomino-thoracic type
Temp : 98.4 F
JVP : not raised
Systemic examination:
Poor oral hygiene.
Inspection- shape of abdomen is uniformly distended with flanks full .
Umbilicus- transverse slit like. No divarication of recti.
Movements of abdominal wall are diminished, all quadrants are moving equally with respiration.
No visible pulsations, peristalsis, sinuses, scars.
Engorged veins present.
External genitalia normal.
Hernial orifices normal.
Palpation:
Superficial palpation – no tenderness, no local rise of temperature.
Measurements
Abdominal girth-78cm
• Xiphisternum to umblicus-25cm
• Umbilicus to pubic symphysis-15 cm,
• spinoumbilical- 14cm on both sides.
Deep palpation:
Liver not palpable
Spleen- not palpable
Hernial orifices & external genitalia normal.
Engorged veins with flow directed away from umbilicus .
Percussion:
Liver dullness present in right 5th inter coastal space.
Fluid thrill present. No shifting dullness.
Traube’s space- dull note.
Auscultation:
Bowel sounds heard.
No arterial bruit or venous hum.
Per rectal examination: normal.
Short case- 2
A 35 yr male, agriculture labourer, came with complaints of
Fever since 25days, low grade with evening rise of temperature
Cough since 20 month
Chest pain since 20 days
Breathlessness since 5 days
General examination
Patient is conscious & coherent
Patient is moderately built and moderately nourished.
Height -160cm. Weight-58kg
BMI-22.7
No Pallor, Jaundice ,Cyanosis ,Clubbing, Pedal edema, lymphadenopathy
No Markers of tuberculosis, HIV, connective tissue disease
No features s/o Horner’s syndrome.
Vital data:
Pulse : 102/min, regular, normal in volume and character and condition of the vessel wall ,no radio-
radial or radio-femoral delay and all peripheral pulses are equally felt.
Blood pressure: 130/70 mm hg in right upper limb in sitting position
Resp .rate: 22cycles/min ,
abdomino-thoracic type
Temp : 98.5 F
JVP : not raised
Systemic examination
Upper respiratory tract:
No nasal flaring, no sinus tenderness, no DNS, no nasal polyps, no turbinate hypertrophy.
Normal oral hygiene, tonsils normal, posterior pharyngeal wall normal.
Lower respiratory tract: Inspection
Trachea appears to be deviated to left side
Trails sign +ve on left side
Apical impulse – visualized in 5th intercostal space
Chest asymmetrical with fullness present on right side of chest
Respiratory movements appears to be decreased anteriorly and posteriorly on right side
Spino-scapular distance--- increased on right side.
No kyphosis, scoliosis, gibbus.
No scars, sinuses, dilated veins over the chest.
Palpation
Trachea –deviation to left
Apical beat– palpable in 5th intercoastal in MCL
No tenderness over chest wall on palpation
Measurements : Antero- posterior diameter---22cm
Transverse diameter--27 cm
Movements of chest wall decreased both anteriorly and posteriorly on the right side.
Tactile Vocal fremitus is decreased in right mammary, axillary,Infra axillary, inter scapular, infra scapular
areas .
VF in other areas -normal.
Inter costal space widening on RIGHT side.
Percussion:
Direct percussion - Both clavicles resonant
Manubrium- resonant, body of sternum- dull.
Indirect percussion:
Tidal percussion:
Traube’s space- tympanic note.
Auscultation :
Vocal resonance:
Diminished in right mammary, axillary, infra axillary, interscapular, infra scapular areas.
All other areas – normal.
No added sounds.
Sucussion splash (-ve).
Other system examination: normal.
