202319633

 

 

 


Case History and Clinical Findings

CHEIF COMPLAINTS:

PATIENT WAS BROUGHT TO THE CASUALITY WITH COMPLAINTS OF SLURRY OF SPEECH SINCE AFTERNOON.

HOPI:

PATIENT WAS APPARENTLY NORMAL 12 YEARS BACK THEN HAD TRAUMA(FALL IN TO WELL)

AND HAD HEAD INJURY

HE DEVELOPED WEAKNESS OF LEFT UPPER AND LOWER LIMBS, WHICH WAS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE, WEAKNESS ASSOCIATED WITH SLURRY SPEECH NO C/O DROOLING OF SALIVA, DEVIATION OF MOUTH

PATIENT TOOK TREATMENT AND THERE WAS IMPROVEMENT IN SYMPTOMS SINCE. THEN ON 04/05/2023 AFTERNOON PATIENT DEVELOPED DIFFICULTY IN SPEECH AND WAS UNABLE TO GET UP FROM BED

PATIENT HAD HISTORY OF TRAUMA 7 DAYS BACK AND INJURY TO LEFT ANKLE (?FRACTURE OF CALCENEUM)

NO INVOLUNTARY MICTURATION AND DEFECATION

 

NO H/O FEVER, VOMITING,PAIN ABDOMEN,LOOSE STOOLS,GIDDINESS H/O CVA 12 YEARS BACK AND ON MEDICATION

K/C/O HTN SINCE 14 YEARS AND ON MEDICATION

K/C/O TYPE 2 DM SINCE 10 YEARS AND ON MEDICATION (GLIMEPERIDE 1MG)

 

 

NOT A K/C/O CAD BA EPILEPSY PERSONAL HISTORY:

DIET: MIXED APPETITE: NORMAL SLEEP: ADEQUATE

H/O SMOKING FOR 40 YEARS

BOWEL AND BLADDER:DECREASED MICTURITION FOR 1 DAY , NORMAL BOWEL MOVEMENTS

 

GENERAL EXAMINATION:

VITALS:

BP 180/100 MMHG PR 62 BPM

RR 18/MIN

SPO2 99% AT RA

NO PALLOR,NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY.

 

 

SYSTEMIC EXAMINATION :: P/A: SOFT NONTENDER CVS:S1S2+ NO MURMURS RS:BAE+ NVBS

 

CENTRAL NERVOUS SYSTEM: PUPILS B/L NSRL GCS:E3V4M6

BULK:NORMAL TONE UL LL

RT INCREASED N LT N N

 

POWER UL LL RT 4/5 4/5

LT 4/5 4/5

REFLEXES B T S K A PLANTAR RT 3+ 2+ 2+ 3+ - EXTENSOR

LT. 2+ 2+ 2+ 2+ - NOT ELICITED

Investigation

CT BRAIN ON 05/05/2023

MULTIPLE HYPODENSE AREAS IN BILATERAL PERIVENTRICULAR WHITE MATTER,CORNA RADIATA, AND CENTRUM SEMI OVALE, SUGGESTIVE PF SMALL VESSEL ISCHEMIC CHANGES

MILD DIFFUSE CEREBRAL AND CEREBELLAR ATROPHY HEMOGRAM:

HB:10.8 MG/DL TLC:11,100

RBC:3.77 MILLIONS/CUMM PLATELETS:2.31L/CUMM HBA1C:6.8% FBS:126MG/DL

LIPID PROFILE

TOTAL CHOLESTEROL:142 MG/DL TRIGLYCERIDES:114MG/DL HDL:40MG/DL

LDL:89 MG/DL VLDL:22.8MG/DL

Treatment Given(Enter only Generic Name)

1. INJ. HAI SC/TID ACCORDING TO GRBS

2. TAB. ECOSPRIN 75/20 PO/HS

3. GRBS 7 POINT PROFILE MONITORING

4. FOLEYS CATHETERIZATION DONE

5.       ITALS MONITORING

 

 


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