63 YR OLD MALE WITH GIDDINESS, SLURRING OF SPEECH, WEAKNESS AND TINGLING OF RT UL & LL

 

Chief complaints: 

                        63 yr old male who is accountant by occupation was brought to casualty with 

                        - giddiness since 20 mins 

                        - slurring of speech since  3 days 

- weakness and tingling numbness of right upper and lower limbs.

History of present illness:

                        Patient was apparently asymptomatic 3 days back , then developed slurring of speech, which is sudden in onset and gradually progressive, not associated with drooling of saliva, no h/o difficulty in chewing & swallowing.

                        -tingling and numbness of rt.hand &rt.foot since 3 days, insidious in onset, gradually ' progressive associated with weakness of rt upper limb & lower limb, slippage of foot wear, no h/ of difficulty in combing hair, difficulty mixing of food(+) since 2 days , giddiness since 20 mins, sudden in onset, rapidly progressive associated with loss of consciousness for 30secs-1 min, not associated with vomitings, involuntary movements, no h/o involuntary micturition 

                         -pt went to local hospital on 05/05/24 - bp:160/80mmhg, took telma 40 mg.

History of past illness:

    -  K/c/o DM since 10 years using- metformin 500 mg BD

     - Not a k/c/o HTN/ CVA/ CAD/ ASTHMA/ TB/ thyroid disorders/ seizure disorders.

Treatment history:

                     Since 10 years on T.metformin 500 mg 

Personal history:

married                           

Occupation:accountant

Diet:mixed

Appetite:normal

Sleep:adequate

Bowel & bladder movements: regular

Addictions: no smoking and alcohol history 

Family history: insignificant

                         GENERAL EXAMINATION:

                         -Patient is conscious, coherent, cooperative , moderately built & nourished

           Height:

           Weight:

           BMI:

          - pallor: absent

          - cyanosis: absent

          - clubbing: absent 

          - icterus: absent

          - lymphadenopathy: absent

          - edema: absent

           Temp: afebrile 

           Pulse rate: 86bpm

           Rr: 22cpm

           Bp:120/80mmhg

           SPO2: 98%

           Grbs492mg%




                                                         


                         SYSTEMIC EXAMINATION:            

                             Cardiovascular system:-  

                             On inspection :-

                               -appears normal in shape

                                -apex beat not visible

                                -no dilated vein, scars, sinuses

                                -no jvp rise 

                               On palpation:-

                               - All inspector findings were confirmed

                               - trachea is central 

                               - no palpable murmurs

                               On percussion:-

                              - heart borders are in normal limit 

                               On auscultation:-

                               - s1, s2 heard (+)

                               Respiratory system:-

                                   BAE(+), NVBS.

                               PER ABDOMEN:-

                                -  No tenderness 

                                -  no palpable mass

                                -  spleen : not palpable

                                -  liver : not palpable 

                                CNS:-

                                - patient is conscious 

                               - dominance- right handed

                               - higher mental functions

                               - memory- immediate, recent and remote

                               - slurring of speech 

                               - B/L pupil reacting to light mid dilated.

                           - tone in all four limbs :

- POWER -                     RT                              LT

               U/L                  4/5                              5/5

               L/L                  4/5                              5/5 

- REFLEXES-             RIGHT                         LEFT

                            B        2+                                 2+

                            T        2+                                 2+

                             S       —                                 —

                             K       2+                                 2+

                             A       —                                 —

        - CRANIAL NERVES EXAMINATION:-

                        - OLFACTORY- INTACT

                        - OPTIC NERVE-  VISION- NORMAL  

                        - EXTRA OCULAR MUSCLES INTACT

                        - TRIGEMINAL NERVE : FACIAL SENSATION IS INTACT 

                        - FACIAL NERVE- FACIAL MUSCLES SENSATION INTACT

                        - VESTIBULO COCHLEAR- HEARING AND BALANCE PRESENT

                        -  IX NERVE- TASTE SENSATION PRESENT 

                        -  X NERVE- NO DIFFICULTY IN SWALLOWING 

                        -  XI NERVE- SHRUGGING OF SHOULDER- PRESENT 

                        -  XII NERVE- NO DEVIATION OF TONGUE

            - CEREBELLAR SIGN:-  

          FINGER - NOSE IN - COORDINATION:- YES

          KNEE - HEEL IN- COORDINATION :- YES  

          - SENSORY SYSTEM:- FINE TOUCH 

                            - PRESSURE INTACT ON BOTH SIDES

                             - PAIN(SUPERFICIAL)                       

          INVESTIGATIONS:-            











   - PROVISIONAL DIAGNOSIS:- 1. ACUTE ISCHEMIC STROKE ( LEFT PONTINE  INFARCT) WITH RIGHT HEMIPARESIS

              2. TYPE II DIABETES MELLITUS :- 10 YEARS

 - TREATMENT:- 

 ON 06/05/24 - 08/05/24

 Pt is c/c/c 

 Temp: 97.8F 

 Bp: 120/80mmhg

 Cvs: s1s2 (+)

 Rs: B/L AE +

 P/A:soft, non tender

CNS- GCS- E4VM6  

     RX:-  1. IVF NS,RL @75 ML/HR

               2. TAB. ECOSPRIN GOLD 75/75/10 

               3. INJ HAI S/C TID 

               4. TAB NEUROBIONFORTE PO/OF

               5. PHYSIOTHERAPY


  ON 09/05/24

- no episodes of giddiness

- no fever spike, stool not passed

     RX:-  1. IVF NS @ 50ML/HL

               2. TAB ECOSPRIN GOLD 75/75/20

               3. INJ HAI S/C TID

               4. TAB LEVIPIL 500 MG

               5. PHYSIOTHERAPY OF RT UL & LL.

                 











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