Long case

 29/F ,homemaker  , unmarried, hailing from chityal, who completed her bsc botany came with complaints of  lethargy ,since 6 months.


history of presenting illness: patient was apparently asymptomatic 6 months back , when she  started developing pedal edema on and off upto ankle, subsided on taking rest and elevating limbs, easy fatiguability on doing daily chores like cooking, cleaning the house.

not associated with ,chest pain, shortness of breath, giddiness,loss of appetite,weight loss.


past history:

12 years back , one afternoon during bathing she suddenly couldnt talk,or move her right upper and lowerlimb,with deviation of angle of mouth to the left ,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 20 days,during which her speech returned and she was able to lift her right upperlimb and walk without support, but still has limp on walking and restricted activity with right hand ,like unable to hold objects,stretch out.

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

Neuro- imaging was done,

she was given one prbc transfusion , started on asprin 150 mg and prednisolone 10 mg which she used for 2 months, and dicontinued treatment on advice of local ayurvedic doctor,she did not follow up thereafter.

3 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 granuloma,started on ATT  and used for 6 months.

there was no history of fever,malaise,loss of weight, myalgias, loss of appetite,swelling in other areas,night sweats,chronic cough or shortness of breath, claudication pain in limbs.

No h/o hypertension, coronary artery disease.




menstrual history:she had history of menorrhagia for 3-4 years at the age of 15-17 ,later on regular cycles ,pads 3 per day for 5 days.


Family history:No similar complaints in the family, she has two other younger sisters


Personal history: appetite is normal, diet consists of lentils,rice, vegetables, less of meat,eggs ,fruits.,she has normal sleep pattern.


General examination:

built: moderate

nourishment:moderate

Pallor:++




icterus-absent

lymphadenopathy:+ posterior cervical ,single lymph node ,mobile,non tender 

cyanosis:absent

clubbing:absent

koilinochya:absent

Pedal edema:absent

contracture present at the right metacarpophalangeal joint.


Pulse

Rate:104/minute

rythmn:normal

volume: normal 

condition of the vessel:normal

                                      Right.                             left

carotid.                      +                                        + 

subclavian.               +.                                     absent

brachial.                     +.                                      absent

radial.                           +.                                     absent

femoral.                       +.                                     +

popliteal.                      +.                                    +

posterior tibialis.      +.                                      +

dorsalis pedis.             +.                                     +

radio femoral delay.   not present

bruit:. heard over abdominal aorta,left carotid artery











Blood pressure 

upper limb                    120/60mmhg.        not recordable

lowerlimb.                      100 mmhg systolic.     100 mmhg

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 function

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

positionnof 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:    deviated to the left 

                  buccinator:.       decreased.              normal

sensory: taste:.                   normal.                    normal




8th: rinnie's.                       normal.                     normal 

          Weber's :no lateralization

9th,10th-

position of uvula:central 

https://youtube.com/shorts/4ZUBBKsDUlE?feature=share

gag reflex                       present.                      present.

11th- scm-.                     normal.                       normal             

            trapezius-.           normal.                        normal 

12th-

           tongue: size,symmetry, 

                                           normal.                         normal

MOTOR SYSTEM:

attitude of limbs:upper limb.                            Normal

                            Semi- Flexion at elbow

                             semi pronated

                             Thumb tucked into palm

     


                              lowerlimb.  

                          Semi -flexed at knee.               normal

bulk:arm:

           forearm:.                24cm.                    25cm

           thigh:.                      38cms.                  39cms.

tone:                                 Right.                     left

           upperlimb.          increased       normal

           lowerlimb.           increased.          normal

https://youtube.com/shorts/TOgT5HdFHv4?feature=share

https://youtube.com/shorts/y4X2Iv28vD4?feature=share

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.      4-/5.                5/5

4) wrist : flexor carpi radialis 3/5.                5/5

                 flexor carpi ulnaris. 3/5.                5/5

                 extensor carpi radialis longus:3/5.      5/5

                 extensor carpi ulnaris longus.  3/5.     5/5

                 extensor digitorium                    3/5.     5/5


handgrip.                                   60%.                  100%

Abductor pollicis longus.        3/5.                     5/5

Abductor pollicis brevis.         3/5.                     5/5

Extensor pollicis longus.         3/5.                      5/5

Extensor pollicis brevis.          3/5.                      5/5

Opponens pollicis.                  3/5.                       5/5

Adductor pollicis.                     3/5.                       5/5

Lumbricals                                 2/5.                      5/5

Interossei -dorsal.                     2/5.                      5/5

                     palmar.                   2/5.                      5/5

https://youtu.be/zG7kyLLaRxk

5)Trunk:abdominal

                             beevor's.               absent

   Hip: iliopsoas.                        4+/5.                     5/5 

             Adductor femoris.        4+/5.                     5/5

            Gluteus medius 4+/5.              5/5

            Gluteus Maximums.             4+/5.             5/5

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

                   extension: quadriceps 4+/5.             5/5





7) ankle: plantar flexion:.             4-/5.              5/5

                     dorsiflexion:.                  4-/5.               5/5

Reflexes:

superficial

corneal.                                    present.                    present

abdominal.                             present.                    present

plantar:.                                   extensor.                  flexion


deep:

https://youtu.be/lxQU_moq6q8

biceps.                                     3+.                                     2+

supinator.                                2+.                                    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.                      normal.                            normal

finger finger.                     normal.                           normal

knee heal.                           normal.                           normal

rebound phenomenon- absent

tandem walking.  - normal 


Gait:

https://youtube.com/shorts/dK3CpEx0TVM?feature=share

 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

CVS:

Apex beat: 5th intercoastal space ,2cms medial to mid clavicular line

No parasternal heave

S1 and S2 heard in all areas.

Respiratory System:

Normal vesicular breath sounds heard in all areas.

GIT:

No tenderness or organomegaly

No evidence of free fluid.


Investigations:

2010

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

Ana:negative

2d echo:normal

Serum creatinine:0.9mg%

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.



KAMINENI HOSPITAL,NARKETPALLE
27th September 2019
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.    


2022 may
CHEST X-RAY(P/A view)


      Haemogram:
Hb:6.1gm/dl
TLC:6500 cells/mm3
Plt:3.78 lakhs/mm3
MCV=62.2fl(decreased)
MCHC:26.6%
PCV:22.9vol%
Rdw:20.2(increased)


ECG:


Peripheral smear:


Anisopoikilocytosis with microcytic hypochromic anemia,pencil forms,tear drop cells and few normocytes seen.

ESR:25mm/hr(elevated)
CRP:negative
Serum ferritin:3.3 ng/ml(decreased)
Serum iron:30 microgm/dl(decreased)
HIV:non reactive
Stool for occult blood: negative

Final diagnosis
Young onset ischaemic CVA with right  hemiparesis with right UMN facial palsy 
With infarct in left MCA territory
Large vessel vasculitis likely takayasu arteritis (aortoarteritis) of left common carotid artery.
Anaemia secondary to iron deficiency
?chronic disease.

Management :
1) Anemia
Iron deficit:b.w*2.3*(15-hb)+500(Ganzoni's equation)
=1500mg
Tab orofer xt /po/bd

2) tab asprin 75 mg/po/od.


Criteria for diagnosis of Takayasu arteritis

2018 Update of the EULAR recommendations for the management of large vessel vasculitis









               



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