case presentation department of medicine .pptx

case presentation department of medicine .pptx

1. CASE PRESENTATION AND REVIEW OF LITERATURE BY SHRUTI SHARMA JUNIOR RESIDENT UNIT 4

2. Patient Details Name- Radha Age/Sex- 36/Female Address- Jubbal,District Shimla DOA-3/3/2024 DOD- 7/3/2024

3. Chief Complaint HEADACHE X 1 month HOPI Patient was in her usual state of health 1 month back when she experienced episodes of headache moderate to severe in intensity Non- Pulsatile in nature Holocranial Increases on coughing Last for 15-20 min 1-2 episode per week

4. H/O relief in the symptoms following the nasal discharge Nasal Discharge Unilateral Right sided clear Watery Increases on bending forward Cannot be sniffed back Remains for 3-4 minutes and subsides No H/O nausea/vomiting No H/O visual disturbances No H/O photophobia/phonophobia No H/O focal neurological deficit/abnormal body movements No H/O fever No H/O head Trauma No H/O suggestive of cranial nerve involvement H/O weight gain of 8-9 kg in previous 1 year

5. Past History Non diabetic, Non Hypertensive, Not on thyroid medication No H/O ATT intake Patient had complaint of headache with nasal Discharge 6 months back and visited hospital for the same where she was given some medications and the patient improved symptomatically. For the past one month patient was not taking medication and again started having similar symptoms

6. Personal History Homemaker Consumes mixed diet Non Alcoholic , Non Smoker Drug History History of OCP intake for 16 months 2 year back

7. Menstrual History P1+0 {1 Fch 3 yr ,Alive and Healthy, Vaginal Delivery,Normal blood loss LMP – 28/02/2023 Regular LACTATION HISTORY- Lactation done for 1 year following birth Family History NO H/O DM, HTN No H/O ATT intake in family

8. EXAMINATION

9. GENERAL PHYSICAL EXAMINATION Patient is calm, conscious, cooperative ,oriented to time,place,person BP-124/80 mm Hg PR-82/min SPO2 –96 % @ RA RBS-141 mg/dl BMI=30 kg/m 2 ( Height-152 cm, Weight-68 kg)

10. Pallor Icterus Cyanosis Clubbing Absent JVP Pedal Edema LAP

11. CNS EXAMINATION Higher Mental function- Normal Speech –Normal Cranial Nerves-WNL Sensory- WNL Motor Bulk –B/L equal Tone- Normal Power –Normal

12. Deep Tendon Reflex Plantar B/L Down Meningeal sign - Absent Cerebellar Sign –Absent Skull and Spine - Normal Right Left Bicep + + Tricep + + Supinator + + Knee + + Ankle + +

13. RESPIRATORY SYSTEM Nose PNS WNL Throat Trachea central Bilateral Vesicular breath sounds No crepts No rhonchi

14. Cardiovascular System Precordium –Normal S1 S2 normal No murmur Appreciated

15. ABDOMINAL EXAMINATION Uniformaly Distended Striae present Umbilicus central and inverted Soft Non tender No organomegaly present Bowel sounds present

16. HEADACHE SINCE JULY 2023 VISITED HOSPITAL IN SEPTEMBER 2023

17. Provisional Diagnosis Headache with CSF Rhinorrhea Etiology - Spontaneous leak---? Raised CSF Pressure Secondary to ? Idiopathic Intracranial Hypertension ?? Cerebral Venous Sinus Thrombosis ??? ICSOL ---- Congenital Cranial Defect ( Progressive Expansion)

18. PLAN Routine Investigations Fundus Examination Radiological NCCT Head + HRCT PNS

19. BLOOD INVESTIGATIONS Hb/TLC/PLT 12/6.6/354 ESR/CRP 16/4.05 Urea/ Creat 21/0.98 Na/K/Cl 139/3.6/109 Ca/Po4 /Mg 9.1/3.2/2.4 Bilirubin Total/Direct 0.3/0.1 ALT/AST/ALP 24/19/76 Cholesterol/TG/LDL/HDL 185/120/72/43 HBA1C 5.3% TSH/T3/T4 1.13/0.64/6.64

20. FUNDUS EXAMINATION FRISEN SCALE Grade 1 Papilledema B/L eye

21. NCCT HEAD Brain parenchyma is normal in Grey White matter differentiation B/L Caudate Nucleus, Thalami ,Basal Ganglia Normal Ventricular system and Extra axial space is grossly Normal Bony calvaria and overlying Soft tissue is Normal in Density IHF is in Midline

22. HRCT PNS

23. D 1 DIAGNOSIS- Headache with CSF Rhinorrhoea Etiology- Skull Defect ( Right Frontoethmoidal Polyposis) with Raised Intracranial Pressure etio ? IIH ??Cerebral Venous Sinus Thrombosis C/D/W SR Neurology MANAGEMENT – Tab acetazolamide 500 mg BD Adv – MRI Brain

24. MRI BRAIN

25. Bilateral Perioptic CSF sleeve Enlarged Meckel cave Posterior Globe Flattening

26. Empty Sella Herniation Of Brain Tissue

27. MR Venography Narrowing of Transverse Sinus

28. NCCT Head-Normal MRI Brain- Perioptic CSF Sleeve B/L Empty Sella Sign Enlarged Meckels Cave MR Venography –Narrowing of B/L Transverse Sinus

29. LUMBURE PUNCTURE Opening Pressure-28cm H 2 Color -clear Cytology -2 cells Negative for malignant cells Sugar 62 (Concomitant RBS=180 mg/dl) Protein 30mg/dl ADA 0.4

30. FINAL DIAGNOSIS Idiopathic Intracranial Hypertension with CSF Rhinorrhoea etio Skull Base Defect- Frontal Meningoencephalocele

31. ENT Opinion- To be taken for Defect closure after ICP lowers Neurosurgery-To be managed conservatively

32. Treatment At Discharge Tab Acetazolamide 500 mg BD Weight Reduction Husky Powder 2 scoops HS Avoid coughing/straining/blowing nose Pneumococcal Vaccination Review after 2 weeks/SOS Attached to ENT OPD and Neurosurgery OPD

33. Current Status Patient has improved clinically and is planned for surgical closure of defect

34. REVIEW OF LITERATURE

35. Idiopathic Intracranial Hypertension IIH and Meningocele Case studies CSF Rhinorrhea

36. IDIOPATHIC INTRACRANIAL HYPERTENSION Also called as Pseudotumor cerebri It is a disorder of elevated CSF pressure. EPIDEMIOLOGY 1/100000 in general population 10-20/100000 in obese More in Females Age – 15-45yr

37. SYMPTOMS

38. PATHOGENESIS

39. MODIFIED DANDY’S CRITERIA

40. MANAGEMENT

41. SHORT COURSE OF STEROIDS CONSIDERED IF NOT RESPONDING WEIGHT LOSS 15 % of weight loss is required to put IIH into remission Achieve— Structured weight loss plan Bariatric Surgery Acetazolamide Dose -250-500 mg BD to max dose of 2 g/day Poorly tolerated/Disease progress despite of max dose- ADD FUROSEMIDE

42. SURGICAL TREATMENT

43. PROCEDURES

44. HEADACHE IN IIH Know the phenotype (  migraine, medication overuse headache, tension-type headache, headache attributed to low CSF pressure secondary to CSF shunting) 68% migraine type headache Treatment – Triptan+NSAID Lifestyle advice should be given

45. IIH AND MENINGOCELE Meningoceles are protrusions of the meninges through points of weakness, usually in the skull base, and are typically categorized into congenital, iatrogenic (after craniotomy or sinus surgery), and spontaneous  In IIH, it arises due to chronic pressure applied by CSF causing weaking of the skull bones and causing herniation of the brain matter. It can present as rhinorrhea , otorrhea, intracranial hypotension, and recurrent bacterial meningitis Most Common Site- Cribriform plate It is seen in 11 % of individuals with IIH

46. Advantage – Better visual outcome Disadvantage- Prone for Meningitis,Pneumocephalous