202305329

 

 



Case History and Clinical Findings COMPLAINTS OF GIDDINESS SINCE 1 DAY COMPLAINTS OF DOUBLE VISION SINCE MORNING

COMPLAINTS OF DIFFICULTY IN SWALLOWING SINCE MORNING COMPLAINTS OF WEAKNESS OF LEFT LOWER LIMB AND INABILITY TO WALK

 

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC TILL YESTERDAY THEN HE HAD 1 EPISODE OF VOMITING - FOOD PARTICLES AS CONTENT, NON PROJECTILE, NON BILIOUS, NON BLOOD STAINED

IN THE EVENING HE DEVELOPED GIDDINESS WHICH HE THOUGHT WAS HYPOGLYCEMIC EPISODE AND HAD A COOL DRINK.

 

THE GIDDINESS DIDN'T SUBSIDE SO HE WENT TO A LOCAL RMP AND FOUND TO BE HAVING SBP OF 90 MMHG AND HENCE FLUIDS WERE GIVEN AND SENT HOME.

AT AROUND 5 AM HE COULDN'T GET UP AND HE NOTICED WEAKNESS OF LEFT LOWER LIMB AND EXPERIENCED SEVERE GIDDINESS AND WAS TAKEN TO A LOCAL HOSPITAL WHERE MRI WAS DONE.

IT WAS FOUND THAT HE HAD ACUTE INFARCTS IN LEFT MEDULLA AND INFERIOR CEREEBLLAR HEMISPHERES.

HE ALSO DEVELOPED DIFFICULTY IN SWALLOWING (SOLIDS>LIQUIDS) AND DIPLOPIA AND WAS REFERRED HERE FOR FURTHER MANAGEMENT

 

PAST ILLNESS:

KNOWN CASE OF DIABETES MELLITUS TYPE II SINCE 10 YEARS (ON OHA)

OPERATED FOR ?APPENDICITIS 3 YEARS AGO AND COLOSTOMY WAS PLACED FOR 3 MONTHS AND WAS DIAGNOSED AS HBSAG POSITIVE AND NOT ON MEDICATION

NOT A KNOWN CASE OF HTN, ASTHMA, CAD, CVD

 

 

PERSONAL HISTORY:

DIET- MIXED

APPETITE- DECREASED

BOWEL AND BLADDER MOVEMENTS- REGULAR SLEEP- ADEQUATE

ADDICTIONS- ALCOHOLIC SINCE 3 YEARS (250ML BRANDY) CIGARETTE SMOKING SINCE 15 YEARS

KHAINI CHEWING SINCE 20 YEARS

 

 

ON EXAMINATION AT ADMISSION:

PATEINT IS CONSCIOUS, COHERENT, COOPERATIVE

NO PALLOR ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA BP- 90/60MMHG

PR- 59BPM RR-18CPM

SPO2- 98%@RA GRBS- 283MG/DL CVS-S1 S2 +

 

RS- BAE+

PA- SOFT NON TENDER CNS-

GCS- E4V5M6

TONE OF BOTH UPPER AND LOWER LIMBS- NORMAL POWER

RT UPPER LIMB- 5/5 LT UPPERLIMB - 4/5 RT LOWERLIMB- 5/5 LT LOWERLIMB- 4/5 REFLEXES-

RIGHT LEFT BICEPS + ++ TRICEPS + ++ SUPINATOR ++ ++ KNEE + +

ANKLE - -

PLANTAR FLEXOR FLEXOR

 

 

GAIT- COULDN'T BE ELICITED

 

 

EXAMINATION AT DISCHARGE:

PATEINT IS CONSCIOUS, COHERENT, COOPERATIVE

NO PALLOR ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA BP- 90/60MMHG

PR- 78BPM RR-17CPM

SPO2- 98%@RA GRBS- 249MG/DL CVS-S1 S2 +

RS- BAE+

PA- SOFT NON TENDER CNS-

GCS- E4V5M6

 

TONE OF BOTH UPPER AND LOWER LIMBS- NORMAL POWER

RT UPPER LIMB- 5/5 LT UPPERLIMB - 4/5 RT LOWERLIMB- 5/5 LT LOWERLIMB- 4/5 REFLEXES-

RIGHT LEFT BICEPS + ++ TRICEPS + ++ SUPINATOR - - KNEE - - ANKLE - -

PLANTAR FLEXION FLEXION

 

 

BRIEF COURSE IN HOSPITAL

PATIENT CAME WITH ABOVE COMPLAINTS WAS STABILISED BY GIVING T. ECOSPRIN 75MG,

T. CLOPITAB 75 MG, T. ATORVAS 10MG. ON INVESTIGATIONS HE WAS TESTED POSITIVE FOR HBSAG AND HIS OUTSIDE MRI SHOWED POSTERIOR CIRCULATION STROKE WITH ACUTE INFARCTS IN LEDT MEDULLA AND INFERIOR CEREBELLAR HEMISPHERE. ANTIPLATELET DRUGS AND STATINS WERE CONTINUED.

HE WAS REFERRED TO OPHTHALMOLOGIST ON 2/2/23 IN VIEW OF RAISED ICT AND ANISOCORIA AND ADVISE FOLLOWED. AS HE WAS KNOWN CASE OF DIABETES ANTI DIABETIC MEDICATION WAS CONTINUED. FOR GIDDINESS INJ PROMETHAZINE WAS ADMINISTERED.

WITH ADEQUATE TREATMENT PATIENT CONDITION IMPROVED AND IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION

Investigation HEMOGRAM ON 2/2/23 HB- 14.7GM/DL

TLC- 12,300 CELLS/CUMM

PLATELETS- 2.6 LAKHS/CUMM

IMPRESSION- NORMOCYTIC NORMOCHROMIC WITH LEUKOCYTOSIS

 

HEMOGRAM ON 4/2/23 HB- 15GM/DL

TLC- 10,200 CELLS/CUMM

PLT- 2.3 LAKHS/CUMM

IMP- NORMOCYTIC NORMOCHROMIC BLOOD PICTURE

 

 

HEMOGRAM ON 5/2/23 HB- 15.4GM/DL

TLC- 7400 CELLS/CUMM

PLT- 2.09 LAKHS/CUMM

IMP- NORMOCYTIC NORMOCHROMIC BLOOD PICTURE

 

 

HEMOGRAM ON 6/2/23 HB- 15GM/DL

TLC- 6100 CELLS/CUMM

PLT- 1.97 LAKHS/CUMM

IMP- NORMOCYTIC NORMOCHROMIC BLOOD PICTURE

 

 

LIPID PROFILE:

TOTAL CHOLESTEROL- 147MG/DL TRIGLYCERIDES- 180MG/DL

HDL- 38MG/DL LDL- 97MG/DL VLDL- 37.8 MG/DL

 

TROPONIN-I - 3834PG/ML

 

 

2D ECHO:

TRIVIAL TR NO MR/AR NO RWMA

TRIVIAL TR, NO MR/AR

NO AS/MS, SCLEROTIC AV

 

GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION NO PAH/PE

 

REVIEW 2D ECHO ON 4/2/23 NO RWMA

TRIVIAL TR, NO MR/AR

NO AS/MS, SCLEROTIC AV

EF=60, GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION

NO PAH/PE

 

 

USG- ABDOMEN GRADE II FATTY LIVER

Treatment Given(Enter only Generic Name)

RT FEEDS - 100ML MILK 4TH HOURLY 50ML WATER 2ND HOURLY T.ECOSPRIN 75MG RT OD

T. CLOPITAB 75MG RT OD

T. ATORVAS 10MG RT HS

T. BACLOFEN10MG RT OD

INJ PROMETHAZINE 25MG IM BD

INJ HUMAN ACTRAPID INSULIN SC TID ACC TO SLIDING SCALE INJ PAN 40MG IV OD

INJ ZOFER 4MG IV BD

Advice at Discharge

T.ECOSPRIN GOLD 75MG PO OD

T. PROMETHAZINE 25MG PO BD

T. GLIMI M1 PO OD

T. BACLOFEN 10MG PO OD

T. METFORMIN 500MG PO OD

Follow Up

REVIEW AFTER 1 WEEK TO GM OPD

 

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY

Discharge Date

Date: 8/2/23

Ward: MEDICAL WARD

Unit: GM IV

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