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
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