CASE PRESENTATION. Dr.ANUSHA GENERAL MEDICINE FIRST YEAR
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1 CASE PRESENTATION Dr.ANUSHA GENERAL MEDICINE FIRST YEAR
2 NAME:XXX AGE:50 SEX:Male OCCUPATION:Agricultural labour ADDRESS:Nalgonda INFORMANT:Patient wife CHIEF COMPLAINTS: 1.Difficulty in walking since 6 months 2.Difficulty in passing urine since 1 month
3 HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 6 months ago then he developed difficulty in initiating walking since 6 months,gradual in onset,not associated with pain. H/o difficulty in remembering events including past and recent things. H/o difficulty in passing urine associated with urgency,increased frequency of micturition since 1 month
4 No H/o trauma No H/o difficulty in mixing food No H/o difficulty in combing hair No H/o difficulty in wearing chappals No H/o difficulty in getting up from squatting position No H/o involuntary movements No H/o bowel incontinence No H/o double vision,blurring of vision No H/o S/o smell disturbances
5 No H/o deviation of mouth No H/o drooling of saliva No H/o decreased hearing No H/o difficulty in swallowing No H/o nasal regurgitation,nasal twan. No H/o difficulty in shrugging shoulders No H/o tingling and numbness No H/o fever No H/o recent vaccination No H/o seizures,syncopal attacks,giddiness
6 No H/o chest pain,difficulty in breathing,palpitations No H/o headache No H/o diarrhoea,vomitings
7 PAST HISTORY: H/O hypertension since 10 years on tab amlodipine 5mg No H/o diabetes mellitus,asthma,tuberculosis,seizures,coronar y artery disease. No H/o similar complaints in the past. DRUG HISTORY : He is on tablet syndopa 110mg half tablet thrice a day since 3 months.(patient diagnosed as Parkinson s Disease in other hospital)
8 FAMILY HISTORY: No history of similar complaints in the family. PERSONAL HISTORY: 1.Diet:Mixed 2.Bowel :Regular 3.Sleep:Adequate 4.Addictions:He is a known occasional alcoholic since 20 years,non smoker.
9 GENERAL EXAMINATION Patient is moderately built,well nourished. BMI:28 Kg/m2 No pallor,no icterus,no clubbing,no cyanosis,no koilonychia,no generalised lymphadenopathy. No muscle wasting
10 VITAL DATA PULSE RATE:82 bpm,regular,normal in volume,normal in character,no radio radial delay,no radio femoral delay. BLOOD PRESSURE:140/90 mm of Hg in right upper limb,supine position and sitting position. TEMPERATURE:99 degree F
11 SYSTEMIC EXAMINATION 1.On examination patient is conscious,cooperative,alert. 2.HIGHER FUNCTIONS: a)level of consciousness:glasgow coma scale:15/15 b)appearance and behaviour:normal c)emotional state: depressed,not hostile d)orientation to time,place,person:present e)no illusions,delusions,hallucinations
12 f)memory: 1.Short term memory:intact 2.Recent memory:intact 3.Past memory:impaired g)speech:normal h)handedness:right handed. MMSE:24/30 3.CRANIUM AND SPINE:NORMAL 4.No signs of meningeal irritation 5.CRANIAL NERVES:NORMAL
13 6.MOTOR FUNCTIONS: a)nutrition: Normal b)tone: RIGHT LEFT i)upper limb: Normal Normal ii)lower limb: Increased Increased c)power: RIGHT LEFT i)upper limb: Normal Normal Ii)Lower limb: Normal Normal d)coordination: i)finger nose test: Normal Ii)Knee heel test: Normal
14 7.SENSORY SYSTEM: a)superficial or exteroceptive: i)pain:normal ii)touch:normal iii)temperature:normal b)deep or proprioceptive: i)vibration sense:normal ii)joint sense:normal Iii)Position sense:normal
15 c)cortical: i)two point discrimination:normal ii)stereognosis:normal iii)graphaesthesia:normal
16 8.REFLEXES: a)superficial: RIGHT LEFT i)abdominal + + Ii)Plantars: No Response B)DEEP: RIGHT LEFT i)biceps jerk + + ii)triceps jerk: + + iii)supinator: iv)knee jerk: v)ankle jerk:
17 9.CEREBELLAR FUNCTIONS: NORMAL 10.AUTONOMIC FUNCTIONS: No postural hypotension,no abnormal sweating,no atrophic changes. 11.GAIT: Magnetic gait,shuffling gait. Other systems examination: CVS:S1,S2 heard,no murmurs RS:BAE+,Normal vesicular breath sounds heard P/A:Soft,no organomegaly
18 PROVISIONAL DIAGNOSIS: Normal pressure hydrocephalus DIFFERENTIAL DIAGNOSIS: 1.Parkinson s Disease 2.Multi infarct dementia
19 INVESTIGATIONS CBP:Hb:13.8gm/dl,TLC:6000/cubic mm,platelets:2.4 lakhs/cubic mm CUE:Normal RBS:80 mg/dl RFT:Normal LFT:Normal ECG:Normal CXR:Normal USG ABDOMEN:Normal HIV Non reactive,hbsag Negative.
20 MRI BRAIN: a)ventricular enlargement out of proportion to sulcal atrophy TREATMENT: About 50 ml of CSF was drained by lumbar puncture under aseptic precautions. Patient s gait improved in 2 days He was referred to Higher Centre for further shunting procedures.
21 THANK YOU
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