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: