GM Case history - 3

 


A 60 year old man, carpenter by occupation came to the casuality with chief complaints of 

Loss of speech since morning 


HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 3 years ago 


3 years back, where he attended a family function and had an binge of alcohol consumption, after a few hrs of consumption, he suddenly developed deviation of angle of mouth towards left side, for which the attenders took him to a local hospital .He was treated conservatively (? Medication unknown) and adviced to use those medications for 1 week.After a week ,his deviation of mouth was resolved.There in the hospital he was diagnosed of having a renal problem ,as B/L pedal edma(pitting type) and facial puffiness was found to be present on examination.Even his creatinine & blood urea was found to be elevated .He was given lasixs and sodium bicarbonate (OD). From then he used to have similar episodes of  B/L pedal edema and facial puffiness which used to get resolved after using medications since 3 years.Since then he quitted his daily routine work and was restricted to home. 


Similar episode occured after 1 year with weakness of right upper and lower limb along with deviation of angle of mouth towards left.He again was taken to a local hospital where conservative management was done .He was then adviced to use medications (Ecospirin, atorvastatin and clopidogrel) & physiotherapy exercises of right UL and LL .He stayed there for 10 days and got discharged.since then patient started using walking aids. 


6 months back he had complaints of pain in the neck and occipital region ,for which they went to hospital and medications were given. pain subsided in 5 days 


Yesterday night after having dinner, 30 mins later he complained of having pain in throat and went to sleep.Today morning while he woke up he lost his speech & was unresponsive.He is conscious and oriented to time ,place and person during the episode.In view of this,he was taken to hospital where his bp was found be 220/120 (medication given) and a MDCT MRI BRAIN         

Was done showing 26 x 56 mm acute hemorrhage in the right lentiform nucleus.He was then referred to kims 


PAST HISTORY : 

He was a k/c/o DM since 5 years 

and HTN since 3 years and was on regular medication 

HTN (Tab Clinidipine 10 mg,tab metoprolol BD and tab clonidine ) 

DM2 (tab gliclazide 40 mg OD) 


5 years back he was operated for lipoma 


Not a k/c/o  TB, CVA, CAD, Asthama ,thyroid and epilesy 


PERSONAL HISTORY : 

Mixed diet 

Sleep adequate 

Appetite normal 

Bowel and bladder movements regular 

He was a known alcoholic since 30 years.Drinks regularly 90 ml whisky.Quitted drinking 3 years back 


GENERAL EXAMINATION : 

Patient is conscious, coherent and cooperative  

Moderately built and moderately nourished  

PALLOR + 

No icterus,clubbing,cyanosis,koilonychia, edema and lymphadenopathy  


VITALS : 

GCS : E4V1M5 

Temp: Afebrile 

PR: 88 bpm  

BP: 170/90 mm hg 

RR: 14 cpm  

Spo2 - 98% at RA  

GRBS - 150 mg/dl  


SYSTEMIC EXAMINATION 

CVS: 

Inspection: 

Chest wall is bilaterally symmetrical. 

No precordial bulge 

Palpation: 

JVP - normal 

Apex beat - felt in the left 5th intercostal space in the mid clavicular line. 

Auscultation: 

S1, S2 heard , No murmurs 


RS : 

Position of trachea: central 

Bilateral air entry + 

NVBS heard 


PER ABDOMEN : 

Soft, non tender 

No organomegaly 

Bowel sounds heard 


CNS : 

Patient is Conscious  

Speech: no response 

Sensory system : not elicited 

Motor system :  

- Bulk : normal 

- TONE:  

           Rt                       Lt 

UL       N                      N 

LL       hypertonia      hypertonia 


- POWER: 

         Rt         Lt 

UL     4/5      4/5 

LL     3+/5      +3/5 


- REFLEXES : 

•Superficial      Rt       Lt 

Corneal  :         +2      +2 

Conjunctival :  +2      +2 

Abdominal :     +2      +2         
















• Deep             Rt        Lt 

Biceps  :          +3        +2 

Triceps :          +3        +2 

Supinator :     +        Absent 

Knee jerk :      +3       +3 

Ankle jerk :      +3       +3 

Plantar :     flexor        flexor 

Cranial nerves: not elicited

No meningeal signs


PROVISIONAL DIAGNOSIS : 

CVA with right sided hemiparesis ? secondary to hypertensive bleed 

? CKD since 3 years

(K/c/o DM type 2 since 5 years & HTN since 3 years)

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