34 YEAR OLD MALE MASON BY OCCUPATION CAME TO THE OPD WITH C/O BLURRING

34 YEAR OLD MALE MASON BY  OCCUPATION CAME TO THE OPD WITH C/O 

Blurring of vision RE greater than LE since 3 yrs not associated with
-headache 
-nausea 
-vomiting 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 yrs back ,while he was doing his work complained of giddiness and fell( black outs)non postural,not associated with nausea, vomitings,vertigo,tinnitus,earfull ness ,he was taken to a local hospital and was diagnosed with HIGH BLOOD PRESSURE ( used medication , unknown) for over 2 1/2 yrs

C/O slurring of speech since 1 year ( progressive) 

C/O body pains since 1 year 0

H/O giddiness 1 week back taken to local hospital ,was on medication ( unknown) 

No C/O chest pain , palpitations, shortness of breath ,pedal edema 

Past History:

K/C/O HTN since 3 yrs (on past atenolol 50mg ,nicardia 10 mg,telma 40 mg) 

Not a K/C/O DM,ASTHMA, EPILEPSY,TB 

Personal History:

He is alcoholic (90ml /day)and smoker ( 2 per day)since 10 yrs 

Family History:

No significant family history 

Vitals on admission: 

BP: 270/140 mm hg (given Nicardia 20 MG and measured bp after 20 mins still the Bp was 270/140 mm hg)
   
PR : 90bpm 

RR: 18 cpm 

All the peripheral pulses present 

Ankle brachial index > 1.25 

Renal bruit present 

BP: RT LT UL 160/100 170/100 LL 200 200 

SYSTEMIC EXAMINATION:

CVS:  
s1, s2 heard 
no murmurs 

RS: 
Nvbs + 
 
P/a: 
soft 
nontender 
 
CNS: 
1) HMF - INTACT 
2)MOTOR SYSTEM : Right Left Bulk: Inspection. N. 
                                     N Palpation. N. 
                                     N Tone: UL. N. N LL. N. N 
                                     Upper Limb: Shoulder: Flexion 5/5. 5/5  
                                                                           Extension. 5/5. 5/5 
                                                                           Abduction: 5/5. 5/5 
                                                                           Adduction: 5/5. 5/5 
                                                           Elbow:    Flexion (biceps) 5/5. 5/5 
                                                                          Extension (triceps) 5/5. 5/5 
                                     Lower Limb: Ilio psoas. 5/5. 5/5 
                                                           Gluteus max. 5/5 5/5 
                                                           Adductor femoris. 5/5 5/5 
                                                           Hamstrings. 5/5 5/5 
                                                           Quadriceps. 5/5 5/5 
                                                           Tibialis ant. 5/5 5/5  
                                                           Tibialis post. 5/5. 5/5 
                                                           Ex. Digitorum L. 5/5. 5/5 
                                                           Fl. Digitorum L. 4/5. 4/5 
                                                           Ex. Hallucis L. 4/5. 4/5 
                                      Deep tendon reflexes: Biceps: +2 +2 
                                                                          Triceps: +1 +1 
                                                                          Supinator: +2 +2  
                                                                          Knee: +3 +3 
                                                                          Ankle: +3 +3 
                                      Plantar: extensor flexor Sensory: STT: Crude touch. + + 
                                                                                                     Pain. + + 
                                                                                                    Temp. + + 
                                      Post. Dorsal Fine touch. present           Vibration. + + 
                                                                                                    Position. + + 
                                      Cranial nerves : II - Blurring if vision present - Rt side > left side. 
                                                                Visual acuity - Right side - only PL/PR present. and
                                                                hand movements perceived. 
                                                               Cant count fingers. Left side - Counting fingers 3 m present. 
                                     III,IV,VI - Extra-ocular movements intact 
                                                      ii) Pupil – Size - 4 mm - B/L NSRL 
                                                      iii) Direct Light Reflex - Present. 
                                     V -             i) Sensory -over face intact  
                                                      ii) Motor – masseter, temporalis, pterygoids 
                                                     iii) Reflex a. Corneal Reflex - present 
                                                                      b. Conjunctival Reflex - present 
                                                                      c. Jaw jerk - present. 
                                    VII - Slight deviation of mouth to left side . 
                                    IX ,X- Uvula deviated to right side .
                                               Gag reflex intact. 
                                    XI, -normal 
                                   XII - no deviation of tongue . 
                                   CEREBELLUM : Heel knee test - normal 
                                                               Finger nose couldn't be performed because of blurring of vision                                                                 Horizontal Nystagmus present . 
                                                               Fast component to left side . 
                                                               Couldn't perform Tandem gait . 
                                                               Bp - Unequal in both arms . 
                                                              All peripheral pulses felt and no asymmetry noted. 

 Cause for his renal artery stenosis? could it be ? takayasu arteritis . ACR criteria - for Takayasu arteritis .(in out pt) 1)Age of 40 years or younger at disease onset - present. 
                  2)Claudication of the extremities - absent 
                  3)Decreased pulsation of one or both brachial arteries - absent ( equal on both sides )                              4)Difference of at least 10 mm Hg in systolic blood pressure between arms - Present . 
                  5) Bruit over one or both subclavian arteries or the abdominal aorta - absent over subclavian. heard over renal artery .
                 6)Arteriographic narrowing or occlusion of the entire aorta, its primary branches, or large arteries in the upper or lower extremities - We dont have evidence yet . have to get CT ANGIOGRAM done .

Investigation:



















Provisional Diagnosis:

Diagnosis : HYPERTENSION SECONDARY TO RIGHT RENAL ARTERY STENOSIS WITH

GRADE IV HYPERTENSIVE RETINOPATHY WITH

RENAL ARTERY STENOSIS SECONDARY TO ? VASCULITIS ? TAKAYASU ARTERITIS WITH

LVH WITH RIGHT FACIAL PALSY WITH SLURRED SPEECH WITH DENGUE FEVER NS1 POSITIVE



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