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
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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