202301360


Case History and Clinical Findings

c/o of slurring of speech and deviation of mouth to the right side since yesterday morning.

HOPI: Patient was apparently asymptomatic 10 years back after which he had a history of a thorn prick to the left middle finger which formed a swelling filled with pus.

-  Patient was diagnosed to have diabetes mellitus, after which his left middle finger was amputated. Since then, the patient is on regular diabetic medication.

-  H/O of burning sensation and tingling in both lower limbs since 1 year

-  Patient is having slurring of speech and deviation of mouth to the right side since yesterday morning

-  No H/O weakness of limbs, seizures, trauma, headache/nausea, or fever.

-  K/C/O DM type 2 since the last 10 years (on regular medication, Glimi M1) EXAMINATION

 

Pt is C/C/C BP:130/80mm hg

 

PR:96bpm RR:20/min GRBS- 261

Temp : Afebrile CVS:S1S2 +,No murmurs

RS :Bilateral air entry present

Normal vesicular breath sounds heard PA- soft, non tender, bowel sounds heard CNS-

 

Pupils- left- Reacting to light

right- dilated, not reacting to light Higher mental functions

-  Conscious

-  Oriented to time,place and person

-  Memory - Intact

-  Speech - slurred

 

 

Cranial nerve examination

•  1 - olfactory sense - normal

 

 

•2- visual acuity present

 

 

•3,4,6 - no ptosis Or nystagmus

 

 

•5- corneal reflex present

 

 

•7- deviation of mouth to right side, loss of nasolabial folds on left side

•  8- Normal hearing

 

 

•9,10- position of uvula is central ,Gag reflex- present

 

 

•11- sternocleidomastoid contraction present

 

 

 

•12- no deviation of tongue

 

 

Motor system

 

 

Reflexes Right Left Biceps - - Triceps - - Supinator - - Knee. 1+. 1+ Ankle. - -

Plantars- Flexion Flexion Power. Lt. Rt

Upper limb -4/5. 4/5

 

 

Lower limb -4/5 4/5 TONE. Lt. Rt

Upper limbs N N Lower limbs N N

No Involuntary movements SENSORY SYSTEM

 

I  –SPINOTHALAMIC R L

1.  Crude touch N N

2.  Pain. N. N

3.  Temperature. N. N

II  –POSTERIOR COLUMN

1.  Fine touch. N. N

2.  Vibration. N. N

3.  Position sense. N. N

4.  Romberg’s sign -Equivocal III –CORTICAL

 

1.  Two point discrimination. N. N

2.  Tactile localisation. N. N

3.  Graphaesthesia. N. N

4.  Stereognosis. N. N CEREBELLAR Tests No Nystagmus

Finger Nose test - normal Heel Knee test - normal Dysdiadokokinesia - normal

 

Investigation

CT SCAN BRAIN : NO E/O ANY HEMORRHAGES IN BRAIN

HYPO DENSE AREA IS SEEN IN RIGHT FRONTAL AREA LIKELY INFRACT USG ABDOMEN : CHOLELITHIASIS

LEFT MILD HYDRONEPHROSIS GRADE 1 PROSTAMEGALY

2D ECHO : AORTIC VALVE CALCIFIED, THICKENED RIGHT ATRIUM AND VENTRICLE NORMAL

LEFT ATRIUM : 3.4 CM

LEFT VENTRICLE : CONCENTRIC LVH ,NO RWMA EDD: 5.17 EF : 58 %

CONCLUSION : MODERATE AR, TRIVAL AR NO MR, NO RWMA, MODERATE AS+, NO MS DIASTOLIC DYSFUNCTION + NO PAH/PE

Treatment Given(Enter only Generic Name) INJ OPTINEURON 1 AMP IN 500 ML/NS IV OD INJ LEVIPIL 500 MG IN 100 ML NS IV BD

TAB ECOSPIRIN 75 MG RT/OD TAB ATORVAS 40 MG RT/HS SYP LACTULOSE 15 ML RT /HS

Advice at Discharge

TAB.LEVIPILL 500MG PO/BD X1WEEK TAB.ECOSPIRIN 75MG PO/OD HSX1WEEK

 

TAB.ATORVAS 40MG PO/OD HSX1WEEK TAB.METFORMIN 500MG PO/OD PHYSIOTHERAPY OF FACIAL MUSCLES SMOKING AND ALCOHOL ABSTINENCE


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