70/m difficulty in walking

 PAPAIAH


70/M 

C/O DIFFICULTY IN WALKING SINCE 3 WEEKS

POOR STREAM OF URINE SINCE 3 WEEKS

BURNING MICTURITION AND FEVER SINCE 2 WEEKS


HISTORY OF PRESENTING ILLNESS

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YEAR BACK AFTER WHICH HE HAD

DEVELOPED SUDDEN ONSET WEAKNESS OF LEFT HAND AND LEG WITH UNCONTROLLED

BLOOD PRESSURE AND WAS DIAGNOSED WITH CVA AND TREATED. FROM THE HE

GRADUALLY STARTED WALKING WITH THE HELP OF A WALKER .NOW SINCE 2 WEEKS

PATIENT AGAIN STARTED DEVELOPING LEFT SIDED WEAKNESS WITH DIFFICULTY IN

GETTING UP AND WALKING HE ALSO HAD DECREASED URINE OUTPUT , RIGHT LOIN PAIN

WITH BURNING MICTURITION FOR WHICH HE WAS INVESTIGATED AND FOUND TO HAVE

RIGHT URETERIC CALICULI CAUSING SEVERE HYDROURETRONEPHROSIS

HISTORY OF FEVER ON AND OFF FOR WHICH HE IS ON IREEGULAR MEDICATION SINCE 2

MONTHS


PAST HISTORY -

K/C/O HTN SINCE 1 YEAR( ON IRREGULAR MEDICATION)

N/K/C/O DM, SEIZURE DISORDER ,TB,ASTHMA,


PERSONAL-

DIET MIXED

DECREASED APPETITE

CHRONIC SMOKER AND 

OCCASIONAL ALCOHOLIC


GENERAL EXAMINATION :

PT IS CONCIOUS , COHERENT AND COOPERATIVE , MODERATLY BUILT AND NOURISHED .

NO PALLOR, ICTERUS , CYANOSIS, CLUBBING ,LYMPHADENOPATHY, EDEMA

TEMP - AFEBRILE

PR- 97 BPM

RR-18 CPM

BP- 140/70 MMHG


SYSTEMIC EXAMINATION :

CVS - S1,S2 HEARD , NO MURMURS

RS - VESICULAR BREATH SOUNDS HEARD , NO WHEEZE AND DYSPNEA,NO CREPTS

P/A- SOFT , NON-TENDER , NO ORGANOMEGALY

CNS -

LEVEL OF CONCIOUSNESS: ALERT

SPEECH: SLURRED

SIGNS OF MENINGEAL IRRITATION: NEGATIVE

CRANIAL NERVES: NAD

MOTOR SYSTEM:

L R


TONE:UL- HYPER NORMAL

LL- HYPER NORMAL

POWER: UL- 3/5 5/5

LL- 3/5 5/5

GLASGOW SCALE: E4V5M6

REFLEXES:

L R

BICEPS 3+ 3+

TRICEPS 3+ 1+

SUPINATOR 3+ 1 +

KNEE 3+ 2+

ANKLE 2+ 2+

PLANTARS- EXTENSOR FLEXOR

NYSTAGMUS- ABSENT

DYSDIADOKINESIA- ABSENT

FINGER TO NOSE-NORMAL

Investigation

HEMOGRAM:29/03/24

HB: 11 MG/DL

TLC: 10,200 CELLS/CUMM

N/L/E/M/B: 76/15/02/07/00

PCV: 34.5 VOL%

MCV: 95.6 FL

MCH: 30.5 PG

MCHC: 31.9 %

RBC COUNT: 3.61 MILLIONS/CUMM

PLATELET COUNT: 1.6 LAKHS/CU.MM

SMEAR:NORMOCYTIC NORMOCHROMIC

RFT 29-03-2024 04:39:PM

UREA 107 mg/dl 50-17 mg/dl

CREATININE 1.9 mg/dl 1.3-0.8 mg/dl

URIC ACID 10.7 mmol/L 7.2-3.5 mmol/L


CALCIUM 9.4 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.4 mg/dl 4.5-2.5 mg/dl

SODIUM 138 mmol/L 145-136 mmol/L

POTASSIUM 4.8 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 106 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 29-03-2024 04:39:PM

Total Bilurubin 1.30 mg/dl 1-0 mg/dl

Direct Bilurubin 0.24 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 58 IU/L 35-0 IU/L

SGPT(ALT) 85 IU/L 45-0 IU/L

ALKALINE PHOSPHATASE 220 IU/L 119-56 IU/L

TOTAL PROTEINS 5.4 gm/dl 8.3-6.4 gm/dl

ALBUMIN 3.17 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.42

COMPLETE URINE EXAMINATION (CUE) 29-03-2024 04:39:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN ++

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 3-4

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

LIPID PROFILR DONE ON 30/3/24

CALCIUM 9.4 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.4 mg/dl 4.5-2.5 mg/dl

SODIUM 138 mmol/L 145-136 mmol/L

POTASSIUM 4.8 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 106 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 29-03-2024 04:39:PM

Total Bilurubin 1.30 mg/dl 1-0 mg/dl

Direct Bilurubin 0.24 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 58 IU/L 35-0 IU/L

SGPT(ALT) 85 IU/L 45-0 IU/L

ALKALINE PHOSPHATASE 220 IU/L 119-56 IU/L

TOTAL PROTEINS 5.4 gm/dl 8.3-6.4 gm/dl

ALBUMIN 3.17 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.42

COMPLETE URINE EXAMINATION (CUE) 29-03-2024 04:39:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN ++

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 3-4

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

LIPID PROFILR DONE ON 30/3/24

TOTAL CHOLESTEROL-92 MG/DL

RFT 01-04-2024 09:49:AM

UREA 43 mg/dl 50-17 mg/dl

CREATININE 1.3 mg/dl 1.3-0.8 mg/dl

URIC ACID 6.1 mmol/L 7.2-3.5 mmol/L

CALCIUM 9.4 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 2.4 mg/dl 4.5-2.5 mg/dl

SODIUM 133 mmol/L 145-136 mmol/L

POTASSIUM 5.1 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 102 mmol/L 98-107 mmol/L

ABG 01-04-2024 12:16:PM

PH 7.49

PCO2 18.9

PO2 57.8

HCO3 14.3

St.HCO3 18.7

BEB -7.0

BEecf -8.5

TCO2 28.7

O2 Sat 93.6

O2 Count 15.2

2DECHO DONE ON 1/4/24

RWA PRESENT ANTERIOR WALL HYPOKINESIA

MODERATE TR WITH MILD PAH

MILD MR WITH MILD AR

SCLEROTIC AV NO AS/MS

EF=53 , RVSP=48MMHG

SERUM ELECTROLYTES (Na, K, C l) 02-04-2024 01:22:AM

SODIUM 134 mmol/L 145-136 mmol/L

POTASSIUM 4.8 mmol/L 5.1-3.5 mmol/L

CHLORIDE 98 mmol/L 98-107 mmol/L


USG CHEST :

RIGHT MODERATE PLEURAL EFFUSION WITH UNDERLYING LUNG COLLAPSE

LEFT MILD PLEURAL EFFUSION WITH UNDERLYING LUNG COLLAPSE


USG ABDOMEN :

LEFT KIDNEY SHOWS RAISED ECHOTEXTURE WITH RENAL CORTICAL CYSTS

MILD ASCITES

RIGHT KIDNEY SHOWS GROSS HYDROURETERO NEPHROSIS


CT KUB :

7-8 MM CALCULI NOTED IN UPPER URETER NEAR PUJ JUNCTION CAUSING SEVERE

HYDROURETERONEPHROSIS


MRI BRAIN:

ACUTE INFARCT IN RIGHT SEMIOVALE

OLD LACUNAR INFARCT IN B/L CORONA RADIATA ,RIGHT THALAMUS,RIGHT SIDE OF PONS


Treatment Given(Enter only Generic Name)

TAB ECOSPIRIN 75 MG +CLOPIDOGREL75 MG+ATORVASTATIN 20 MG PO /HS AT 9PM

TAB FUROSEMIDE 20 MG PO/TWICE DAILY 8 AM ----------3 PM

TAB TELMA 40 MG PO OD AT 8 AM

TAB TAMSULOSIN 0.4 MG PO OD AT 8 PM

TAB CILNIDIPINE 10 MG PO OD AT 8 AM

MONITOR BP PR RR SPO2 4 TH HOURLY

Advice at Discharge

TAB ECOSPIRIN 75 MG +CLOPIDOGREL75 MG+ATORVASTATIN 20 MG PO /HS AT 9PM

TAB FUROSEMIDE 20 MG PO/TWICE DAILY 8 AM ----------3 PM

TAB TELMA 40 MG PO OD AT 8 AM

TAB TAMSULOSIN 0.4 MG PO OD AT 8 PM

PHYSIOTHERAPY OF RIGHT UPPER AND LOWER LIMB



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