Dr.bhavin Case Presentation

7/27/2019 Dr.bhavin Case Presentation

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welcome


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ByDr. Bhavin Kathiriya2nd yr p GDept. of Kayachikitsa.


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Name : Vitthal Poojary

Age : 58 yrs

Sex : male

Address: Sanna Mane Nilaya,Kedoor.

Marital status: Married Occupation: Canteen owner

I.P.No: 72353

Date of admission : 03/12/11

Date of discharge : 12/12/11


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Pt c/oGradual loss of strength in Right UL & LL since 4 months;

stands with support but cant walk.

Repeated episodes of seizers Once /10 Days since 4 months.

Associated complaint:Headache ( on and off pricking type of pain) & slurred

speech since 4 months.


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A 58 yr old male patient was apparently normal 4 month back

Pt was running a canteen ;on 8thAug11 at 9 am while workingin hotel Pt suddenly developed involuntary jourkeymovements of right hand along with severe headache which

was continued for 5 min followed by unconsciousness for 10

min. Pt had been suffering from headache before that also(was on and off pricking type of pain)

Pt was shifted to local practitioner and found slight raised BP;he was referred to nursing Home and got admitted in ICU for 1

day. During ICU stay Pt was conscious ;BP was normal. Ptgradually started feeling slight weakness of right UL andSlurred speech. A CT brain was performed which came out

with Multiple small calcified lesions in B/L Frontal, leftTemporal & right Occipital lobes with evidence of oedemanoted in left frontal lobe lesion.


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He was immediately again shifted to KMC,Manipal and gotadmitted for 13 days and was given prophylactic treatment.During this period Pt c/o epileptic seizure once per 2-3 days

which was of mostly right hand and leg. gradually duringhospitalization pt felt numbness in right lower limbfollowed by reduced strength in both right UL & LL(morein lower limb). There was no history of fever,breathlessness ;no h/0 urinary or fecal incontinence during

this period. After 13 days pt was discharged. he was not able to walk and

used to stand with support. There was on & off prickingtype of pain which was leading to restlessness to thepatient , epileptic seizure attack was reduced to 1 per 10

days .So for the above said chief complaints the patient gotadmitted to SDM HOSPITAL for better relief. Patient is K/C/O HTN since 4 months and under

medication & Not a k/c/o DM.


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K/C/O alcoholism & chronic smoking.

Operated for RTA injury at right fore-arm.


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All family members are said to be healthy (wife and 2 daughter).

Belongs to lower middle class.


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Appetite : Decreased

Diet: mixed ( non veg Pork)

Sleep : Disturbed

Bowels : constipated (Once/2-3 day)

Micturition : 4-5 times /day; 2 times / night. Habits : alcohol : 1 quarter / day since 15 years ( local brand).

Beedi : 5 beedies / day


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Appearance - NormalBuilt - NormosthenicNutrition - Moderatly nourished

Cyanosis - abPallor - ab

Icterus - AbOedema - abHeight - 159cms

Weight - 73 kg

Tongue - UncoatedLymphadenopathy- abGait - Altered. Hemiplegic gateSpeech - Dysarthria


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Temp - 98.6*FPulse - rate 78/minResp rate - 22/minB.P - 130/90 mm of Hg

J.V.P. - not raised.


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CVS EXAMINATION-

S1 & S2 heard , no added sounds..

RESPIRATORY SYSTEM EXAMINATION-

Normal vesicular breath sounds, no creps , No added sound.


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HIGHER MENTAL FUNCTIONS:-

Conscious level fully conscious

Orientation Time, Place and person- present

Intelligence Normal

Memory Immediate, Recent and Remote are normal Hallucination, Delusion and Illusion Absent.

Speech- Dysarthria present.


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1. Olfactory & Smell sensation Intact & symmetrical both sides.2. Optic

Normal (Color Vision, visual Field, and Accommodation reflex.)

Acuity- Myopic,light reflex intactforward bulging of eye- absent

3,4 & 6 Occulomotor ,Trochlear , Abducent -Eye ball movement- intact

Pupil :

Size ,position and Shape-intact;convulsion & Ptosis--absent .5. Trigeminal-

sensory- sensation over face - intactMotor- Clenching of teeth-symmetrical

Lateral movt of jaw- symmetrical

Reflex- Corneal - intact.jaw reflex- intact.

7. Facial-Fore head furrowing-- symEyebrow raising symmEye closure Symm

Teeth showing Symm


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Blowing the cheek SymmNasolabial fold-- normal symm B/LTaste sensation of anterior 2/3 of tongue- intact.

8.Vestibulo Cochlear Tuning Fork test- notelicited.

9& 10. Glossopharyngeal & Vagus.Taste Sensation in Posterior 1/3- intactPosition of uvula central.Movement of Palate- intact(air blow- normal)

11. AccessoryDissymmetry of shoulders .shrugging the shoulder possible on left side only.

Turning of neck left side-intactright side- affected12. Hypoglossal position of tongue normal.

protrusion of tongue - absent.Wasting & deviation- Absent

Dysarthria- present.


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Attitude of limb:

Rt LtL.L: Knee & ankle extended. Knee extended,externally rotated

U.L: adducted n flexed. intact

Nutrition: moderately nourished

Tone: UL & LL Rt Lt

Hypertonic Isotonic

Spasticity- absent absent

Rigidity - present absentRt Lt

Power : UL 3/5 5/5

LL 2/5 5/5

Wasting : Rt-forearm ; lt- intact


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Co- ordination: Rt Lt

Finger nose test: affected intact

Knee heal test: affected intact

Involuntary movements : absent

GAIT: Hemiplegic gate.Reflexes:

Plantar-Babinskis sign- Rt: +ve , Lt: -ve

Dysdiadochokinesis Present.


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Deep tendon reflexes

Rt Lt Upper limb Biceps - Exaggerated(++) Normal

Triceps - Exaggerated(++) NormalWrist jerksExaggerated (++) Normal

Lower limbKnee jerk - Exaggerated (+++) NormalAnkle jerk - Exaggerated (+++) Normal

Superficial reflexes Corneal reflex Normal Normal Pupillay reflex - Normal Normal Abdominal reflex Diminished(-) Normal Clonus - Absent Absent


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Sensory system examinationsuperficial Touch - intact B/LTemp intact B/LPain intact B/L

DeepCrude touch, Vibration, Joint sensation, Position SensePressure sence ---Intact B/L.Cortical

Tactile localisation- Rt (L.L.-affected) ; Lt( intact )

Graphaesthesia intactDysgraphia- absentstereognosis- intect.


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CEREBELLAR SIGN:

Nystagmus- Absent

Dyspraxia-present

Intension tremor- absent

Dysdiadokokinesis- PresentKnee heal incordination-present.

Tandom walking- absent.

Meningeal sign-Neck stiffness- absent

Kernigs sign absent

Brudzunskis sign negative


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COMPLETE BLOOD COUNT

Hb 12.75 gms%

WBC 8000 cells/cumm

ESR 14 mm/hr

DIFF. COUNT OF WBC

N 68%

L 24%

Eosinophils 7%

Monocytes 1 %

Basophil 0 %

Total RBC 3.9 millions /cumm

Platelet count 3.1 lakhs / cumm

PCV (Hct) 34.2 %

MCV 86.7 fl

MCH 32.4 pg

MCHC 37.4 gms %

RDW-CV 14.1 %


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Random Glucose : 103 mg/dl ( 60 -140 ) Blood Urea : 18 mg/dl (10-50)

Serum creatinine : 0.8 mg/dl (0.6-1.4)

Serum Uric Acid : 3.8 mg/dl (1.5-7)


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Total cholesterol : 172 mg/dl

Triglycerides: 143 mg/dl

HDL-Cholesterol : 36 mg/dl

LDL-Cholesterol : 107 mg/dl VLDL-cholesterol : 29 mg/dl

TC/HDL Ratio : 4.8 Ratio( 3-5 Avg. Risk)

LDL/HDL Ratio : 3 Ratio


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Negative ( 5/12/11 )


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Chemical examination:

albumin- nil

sugar- nil

Microscopical examination:

epithelial cells: 1-2/hpf (3-5/hpf normal value)Pus cells: 1-2/hpf (1-2/hpf normal value)

RBCs: 0-1/hpf (0-1/hpf normal )

Crystals: nilCasts: nil

Any other: nil


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10 aug11

Multiple (about 5 ) small calcified lesions in bilateral frontal ,left temporal & right occipital lobes with evidence ofoedema noted in left frontal lobe lesion.

Possibility : 1) cerebral cysticercosis.

2) calcified tuberculomas.05 dec11

Multiple peripherally enhancing thin walled cystic lesionswith eccentric calcified nodules noted in bilateral cerebral

and cerebellar hemispheres, largest measuring 40 mm indiameter in the left frontal lobe, consistent withcysticercosis. Few small calcified nodules are also noted.


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Brain abscess

Subdural Empyema

Bacterial meningitis Todds paralysis.

Primary brain tumors.

Neurocysticercosis


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Neurocysticercosis .

Cysticercosis present insmooth muscles.Cysticercosis present in brain


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Etiology : NCC is the most common parasitic disease of theCNS worldwide. Humans acquire cysticercosis by theingestion of food contaminated with the eggs of theparasite T. solium. Eggs are contained in undercooked porkor in drinking water or other foods contaminated with

human feces Clinical presentation :Onset of partial seizures with or without secondarygeneralization.

Cysticerci may develop in the brain parenchyma and cause

seizures or focal neurological deficits.If present in subarachnoid or ventricular spaces, cysticerci

can produce increased ICP by interference with CSF flow.


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A) Visiculat syst: MRI ,well definedscolex, minimal contrast enhancement

B) Colloidal cyst : MRI , ring enhancement,loss of scolex, perilesional oedema

C) Nodular cyst : Nodules with diffusedenhancement and no cystic component

D) Calcified granuloma: non-contrast CTshowing multiple punctuate calcification


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Tab Eptoin 100 mg 0-0-3

Tab Eptoin 50 mg 0-0-1

Tab gardinal 60 mg 0-0-1

Tab Acamprol 333 mg OD

Tab TIM 100 mg OD

Tab Ativan 1 mg OD Tab Nicochew 4 mg OD

Tab Amlokind H 5mg OD

TREATMENT GIVEN AFTER ADDMISSION IN SDMH :

Tab Albendazole 400 mg 1 OD ( for 15 days )Contined Eptoin 100mg 3 OD & Eptoin 50 mg 1 OD


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Nadi 78/min

Mutra prakrita (6 times/day)

Mala vikruta (once/2-3day)

Jivha Alipta Shabda vikruta

Sparsha Prakrut

Drik Prakruta

Akriti Madhyama.


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Dasa vidha pareeksha

Prakriti: pitaja-vataj (chapala gati, chesta, bahupralapa,ushna asahishnuta, sheta preeyata,

guru gatra, kshuda, sweda adhikata) Vikriti: Dosha- Tridosha(karmahani,sparsh agnatatva, stabdhata,

shiro ruja, nidranasha, bala-alpata, gadha varchas,

murchcha, dorgandhya,kandu)Dhatu- Rakta, mamsa,Updhatu Sira, Snayu.

Saara: avara sara(twak saara- snigdha,)(rakta saara- snigdhata of nakha, mukha)

(mamsa saara- upachaya of hanu, udara)(meda saara- snigdhata of kesha,loma)(asthi saara- nothing specific)(majja saara- mrudu anga)(shukra saara- nothing specific)

(satva saara- nothing specific).


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Samhanana: madhyama

Saatmya: madhyama

Satva: avara

Pramaana: madhyama Vaya: Madhyama

Vyayama shakti: poorvakaalina: madhyama

adhyatana: avara

Ahara shakti: abhyavarana shakti: madhyama

jarana shakti: avara


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Nidana: - aaharaja: ajirna bhojan, sankirna bhojana, virudhdha

Ahara ( parihar virudhdha) Poorvaroopa: shirshool.

Roopa: karma kashaya(right UL & LL) . Vak sanga, shiroshula,akshepaka,dorgandhyata,karna nad, mano vibhramsha.

Upashaya anupashaya: nothing specific


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Ajirna bhojan,sankirna bhojana-viruddha ahara

(varaha mansa sevetoshna-pariharvirdhdha)

Klinnata Utpatti in rakta & mamsa& Kopana of Tridosha

Uttpati of Raktaja krimiLodges into Raktavaha dhamani

Reaches to murdhini

KRIMI SHIRO ROGA(Raktaja)Raktaja Krimi does Shira

Snayu Bhakshana

Bala Kshaya and Shosha

Vata vrudhdhi

Sthana samshraya in shira snayu

Leads to Dakshina ParshvaKarma Hani

Leads to Dhatu Kshayajanya Pakshaghat


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Dosha: Tridosha

Dushya: rakta, mamsa

Agni: jatharagni

Srotas: mansavaha,raktavaha.

Srotodusthi: sanga. Udbhava sthana: pakvashya

Vyakta sthana: shiras n dakshina hast-pada.

Rogamarga: madhayama .


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Shiro Krimi janya Pakshaghat. Marga-avaranjanya pakshghata (kaph-pita

anubandh).

Ekanga vata.


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Shiro Krimi janya Pakshaghat.


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Shat dharana yoga (in Arohana krama 16-19-22-25-28-31-34).

Abhyanga with M.N. taila.

Shiva Gutika 1-0-0

Tab cruel 1-1-1

Nitya virechana with Shunthi kashaya 20 ml &Eranda taila 20 ml ( at 6 AM)

Physiotherapy .


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Abhyanga

Snigdha sweda

Mrudu Virechana

Shirovirechana

Some yogas

Ekangavera rasa, brihat vata cintamani rasa, dhanadanayanadikashaya, sameerpannag rasa,maha vidhvansak rasa, shiva

gutika, dasamularista, balarista.


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