MD EXAM----->LONG CASE

 30/F,homemaker,unmarried, hailing from chityal, who completed her bsc botany came with 

COMPLAINTS :-

 Lethargy-----> since 6 months

HISTORY OF PRESENT ILLNESS :-

Patient was apparently asymptomatic 6 months back then she had insidious onset of lethargy, 

easy fatiguability on doing daily chores like cooking, cleaning the house.

No history of any fever, cough,Loss of appetitie,weight loss,chest pain, palpitations,pedal edema

No menstural abnormalities

PAST HISTORY :-

At her 17years of age(in year 2010),One afternoon while bathing, she suddenly developed weakness 

of right upper limb and lower limb, along with deviation of mouth to left side upon which she made 

sounds , her  mother who was nearby came to her aid ,and she was taken to hospital in nalgonda 

within an hour,and referred to gandhi hospital where she was admitted for 1month,during which her 

speech returned.She was able to walk without support after 1month,but still has limp on walking.

Weakness of the right upper limb persisted,like unable to lift the hand,hold objects, stretch out.

This episode was not associated with blurring of vision, vomiting,headache,loss of consciousness tingling ,numbness, involuntary movements, swallowing difficulty.

4 years back in 2019 she presented to Kamineni narketpally with complaints of painful swelling 

in the left side of the neck, for which usg guided fnac was done showing caseating 

 granuloma,started on ATT  and used for 6 months.

No h/o hypertension,diabetes,thyroid disorders,coronary artery disease.

FAMILY HISTORY:-

No similar complaints in the family.she has one elder and one younger sister

PERSONAL HISTORY:-

Appetite is normal, diet consists of lentils,rice, vegetables, less of meat,eggs ,fruits.

GENERAL EXAMINATION :-

Patient is conscious, coherent,co-operative.Moderately built and nourished

Pallor +

Icterus -

Cyanosis -

Clubbing -

Lymphadenopathy + :posterior cervical ,lymph node ,mobile,non tender 

-Contracture present at the right metacarpophalangeal joint.

VITALS :

Pulse:-90/min,right arm,regular rhythm,normal volume

Arteries                       Right.                                Left

Carotid.                         +                                        + 

Subclavian.                   +.                                     absent

Brachial.                       +.                                     absent

Radial.                           +.                                     absent

Femoral.                       +.                                     +

Popliteal.                      +.                                    +

Posterior tibialis.          +.                                    +

Dorsalis pedis.             +.                                     +

Radio femoral delay.   not present

Bruit: heard over right and left carotid artery

Blood pressure                 Right                       Left

upper limb                    150/90mmhg.              not recordable

lowerlimb.                    120 mmhg systolic.     120 mmhg

Respiratory rate-22cycles per min

JVP-Not elevated

Grbs-120mg/dl

SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM

Right/left handed person :initially right,then learnt to write with left hand since 12 years

Education:Bsc botany

HIGHER MENTAL FUNCTIONS :conscious,oriented

Memory: intact (immediate,recent,remote)

Speech:

comprehension:+

fluency+

repetition+

reading+

writing+

naming objects+

CRANIAL NERVES.       Right.                       Left

1-olfactory:                    present.                 present

2-visual acuity:              normal.                  normal

            Visual field:confrontation method:normal

            Colour vision:normal

            Fundus:             normal.                normal.

3,4,6

eyelids :.                             normal.          normal

position of eyeball at rest: normal.          normal

extraocular movements :.  normal.          normal 

pupil :size,shape               normal.         normal 

direct and indirect light reflex: present.   present

5:

sensory:          touch.              present.                   present

                        pain.                present.                  present

                        temperature.    present.                 present 

motor: side to side jaw movement  normal

reflexes:         corneal.           present.                present

                       jaw jerk.          present.                present

7th- 

motor-       frontalis.                normal.                normal

                  orbicularis oculus: normal.              normal

                 orbicularis oris:      normal                normal

                  buccinator:.          normal                normal

sensory: taste:.                  normal.                   normal

8th:  Rinnie's.                       normal.                     normal 

        Weber's :No lateralization

9th,10th-

       Position of uvula:central 

       Gag reflex                       present.                      present.

11th-    SCM-.                     normal.                       normal             

            Trapezius-.             normal.                        normal 

12th-

           Tongue: size,symmetry, 

                                           normal.                         normal

MOTOR SYSTEM:

Attitude of limbs:

   Upper limb.

                                              Right                                  Left     

                              Semi- Flexion at elbow                     Normal

                              Semi pronated

                              Thumb tucked into palm

    Lower limb.  

                            Semi -flexed at knee.                    normal

Bulk:arm:

           forearm:.                24cm.                              25cm

           Thigh:.                    38cms.                           39cms.

Tone:                              

           upperlimb.          increased                             normal

           lowerlimb.           increased.                            normal

Power:

1)Neck:.       flexors:.        normal.               normal

                     extension:.  normal.              normal

2) shoulder:  Supraspinatus.   4-/5.                  5/5

                     Deltoid:.            4-/5.                  5/5

                      Infraspinatus:.  4-/5.               5/5

                      Latissimus dorsi :4-/5.         5/5

                      Serratus anterior:  4-/5.        5/5

                       Pectoralis major:.   4-/5.       5/5 

                        Rhomboids  4-/5.                  5/5

3)elbow: biceps.                     4-/5.                  5/5

                 Triceps.                   4-/5.                   5/5

                  Brachioradialis.      Not able to pronate               5/5

4) wrist : flexor carpi radialis     Not   able to flex             5/5

                 flexor carpi ulnaris.     Not   able to flex                         5/5

                 extensor carpi radialis longus: Not able to extend      5/5

                 extensor carpi ulnaris longus.  Not able to extend      5/5

                                extensor digitorium :  Not able to extend     5/5

Handgrip.                                   60%.                                         100%

Abductor pollicis longus.          Not able to abduct                        5/5

Abductor pollicis brevis.         Not able to abduct                           5/5

Extensor pollicis longus.         Not able to extend                          5/5

Extensor pollicis brevis.          Not able to extend                          5/5

Opponens pollicis.                  Not able to perform.                        5/5

Adductor pollicis.                    Not able to adduct                           5/5

Lumbricals                              Not able to Perform                         5/5

Interossei   -dorsal.                Not able to Perform                          5/5

                     palmar.               Not able to Perform                        5/5

5)Trunk:abdominal

                             Beevor's - absent

 6)Hip:   Iliopsoas.                        4+/5.                   5/5 

            Adductor femoris.             4+/5.                   5/5

            Gluteus medius                4+/5.                  5/5

            Gluteus Maximums.         4+/5.                  5/5

7)knee: flexion: hamstrings.    4+/5.              5/5

            extension: quadriceps 4+/5.             5/5

7) Ankle:      Plantar flexion:.             Not able to perform              5/5

                     Dorsiflexion:.                Not able to perform             5/5

Reflexes:

Superficial

corneal.                                    present.                    present

abdominal.                             present.                    present

plantar:.                                   extensor.                  flexion

Deep

Right upper limb Reflexes

Knee reflex

biceps.                                     3+.                                     2+

supinator.                                3+.                                    2+

triceps.                                     3+.                                    2+

knee jerk.                                3+.                                    2+

ankle jerk.                               +1.                                     +1

No clonus

Sensory:. in all dermatomes

fine touch.                           present.                           present 

joint position.                       present.                          present 

vibration.                              present.                          present

crude touch.                        present.                          present

pain.                                   present.                            present

temperature.                      present.                            present

Romberg's test: negative(no sway)

cerebellum:

finger nose.                      Not able to perform                       normal

finger finger.                     Not able to perform                       normal

knee heal.                           normal.                                       normal

rebound phenomenon- absent

tandem walking.  - normal 

Gait :-Gait Video

circumduction on the right,

Toes touching the ground first

pace:normal

falling to sides:absent

hand swing:.                    absent                           present

turn:.             normal 

Autonomic nervous system:normal

Meningeal signs:absent

CARDIOVASCULAR SYSTEM :

-Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1 S2 heard

-No murmurs

RESPIRATORY SYSTEM

  Upper respiratory tract normal

  Lower respiratory tract :

-Left supraclavicular fullness present

-Trachea is central

-Movements are equal on both sides

-On percussion resonant on all areas

-Bilateral air entry equal

-Normal vesicular breath sounds heard

-No added sounds

-Vocal resonance equal on both sides in all areas

PER ABDOMEN :

-Scaphoid

-No visible pulsations/engorged veins/sinuses

-Soft,non tender, no guarding and rigidity, no organomegaly

-Bowel sounds heard,No abdominal Bruit

PROVISIONAL DIAGNOSIS :

Young onset CVA : Right hemiparesis with Residual weakness of right upper limb with flexion deformity at right wrist

Vasculitis(?Takayasu Arteritis)

Left cervical Lymphadenopathy(Past history of TB,Used ATT for 6months)

INVESTIGATIONS :

2010

Hb: 7.5gm/dl,TLC-8500 cells/mm3, adequate platelets

Ana:negative

2d echo:normal

Serum creatinine:0.9mg%

GOVT HOSPITAL,HYDERABAD

  19 th january 2010

Previous reports

CT BRAIN(plain):

Hypoensity is seen in left capsulo ganglionic region and parigete temporal lobes with compression over left lateral ventricle.

IMPRESSION: ACUTE LEFT MCA INFARCT.

CAROTID DOPPLER: 

RIGHT CCA:

shows diffuse circumferencial thickening 1.3m causing 30-40% in proximal and mid portion of cca. Causing obstruction and reduced flow velocities.

Distal cca and bulb,both internal and external carotid arteries show thrombosis causing obliteration of lumen 60%.with reduced flow velocities 

LEFT CCA: 

Filled echogenic material s/o thrombus from origin causing NEAR TOTAL obstruction and minimal color flow filling.

The thrombus extending Upto bulb,ICA and ECA causing partial obstruction and reduced flow velocity.

IMPRESSION: B/L CAROTID THROMBOSIS,DIFFUSE ON LEFT SIDE.

b/l vertebral arteries show NORMAL color flow filling and velocities.

CT AORTIC ANGIOGRAM:

Narrowing at origin of inferior mesenteric artery.

-Diffuse narrowing of right common carotid artery.

-There is narrowing of origin of left common carotid artery and no opacification of distal left common carotid artery 

-Left subclavian artery is normal near the origin.There is diffuse narrowing of subclavian artery distal to origin of vertebral artery.

-E/o collateral seen in left supra scapular region.

-Irregular narrowing of thoracic aorta is seen.

IMPRESSION:Features are suggestive of AORTOARTERITIS.

27th September 2019,Private hospital 

Esr: 15mm/hr(normal)

Swelling over left posterior side of neck

Fnac IMPRESSION:Features are in favor of Granulomatous Lymphadenitis possible of T.B etiology.