GENERAL MEDICINE CASE

Shivani Kommera 

70 Year old Male with altered sensorium .


• A 70 year old male , farmer by occupation came to the casualty with chief complaints of loss of consciousness and  sudden loss of speech since yesterday night .

History of present illness -

• Patient was apparently asymptomatic till yesterday , then he suddenly woke up from his bed at 11pm to go to washroom and suddenly he fell from his bed .
• Then the patient attenders observed Loss of speech and he is unable to wakeup from the floor .
•  H/o of tingling sensation bilateral upper and lower limbs since 1 month .
•  H/o Fever 5 days back and not associated with chills and rigors .
• No H/o Trauma to Head 
• No involuntary micturation and defecation .
• No H/o Nausea / vomitings 
• No H/o of Pedal edema 
• No difficulty in breathing observed 
• No H/o Burning micturation .

Past History -

• k/c/o DM & HTN since 1 year and on irregular     medication .
• Not k/c/o Asthma , TB , Epilepsy 
• Alcoholic + occasionally ( last 1 week back ) 
• Smoking (1 chutta/day) since 45 years .


Personal History - 
Marital status - Married 
Diet - Mixed 
Appetite - Normal 
Sleep - adequate 
Bowel & Bladder movements - Regular 

Family History -
No family history of DM, HTN, Asthma Epilepsy, cardiovascular diseases ,TB .

General examination - 

No pallor 
 Icterus + 
No Cyanosis 
Clubbing + 
No lymphadenopathy 
No pedal oedema 


O/E -
 Patient was Conscious , non coherent , non co operative 

Vitals on admission  - 

Temperature - 98.6 F
Blood pressure - 140/90 mmHg
Pulse rate - 114 bpm
Respiratory rate - 28 breaths/min
Spo2 - 99% on 6 Litres O2 

Systemic Examination -

CVS - S1 S2 Heard 

RS - Bilateral Air Entry + Normal Vesicular Breath Sounds + 

P/A - Soft , non tender 
Bowel sounds heard 

CNS - 
Patient was conscious , non coherent , non cooperative .

GCS - 8/15 


MOTOR SYSTEM 

                         Right.                Left 

Tone      UL     Normal            Normal 
              LL.     Normal.           Normal 

Power.   UL       3/5.                   3/5
               LL       3/5                   3/5 


REFLEXES 

Reflexes Biceps triceps supinator knee ankle 

Right        2+        3+          +              +        +

Left          3+        3+         3+            2+        2+

       • pupil - Normal size , reactive to light 

       

Lab diagnosis - 

CBP - shows Thrombocytopenia

    RFT - Shows Hypokalemia with increase in Urea creatinine .




LFT - shows raised Bilirubin , raised Alkaline phosphate and Hypoproteinemia 



CXR - Shows Cardiomegaly and  some
 consolidations.

 Diagnosis - ISCHEMIC CVA (TEMPORAL REGION) MIDDLE CEREBRAL ARTERY TERRITORY .

Rx

1.TAB. ASPIRIN 150 mg + CLOPIDOGREL 75mg OD
2. ATORVASTATIN 40mg OD.
3. IVF(NS,RL)@ 75 ml/hr
4..INJ PAN 40MG/OD.
5.INJ ZOFER 4MG/TID.
6.RT FEEDS(100ML OF WATER,100ML OF MILK WITH PROTEIN POWDER) 4TH HRLY 
7.INJ NEOMOL 1G/1V/SOS.
8.TAB METFORMIN 500 MG OD 
9.BP,PR,SPO2 HRLY MONITORING,GRBS 6HRLY 
10.NEB WITH BUDECORT AND IPRAVENT(STAT) & @ 6LIT OF O2/MIN


This is an ongoing case and details will be updated .

This elog was done under guidence of Dr.Vara Prasad (2016)



            

         

             







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