67 yr old M not responding to words, commands, unable to speak and swallow

 A 67 yrs old male came to opd with chief complaints  of  not responding to words and commands ,unable to swallow,unable to speak since 1 day (30/8/22).



History of present illness 

Patient was admitted with complaints of unable to speak,swallow and altered sensorium which was sudden in onset.

In 2012 he heart blocks  in two valves for which he underwent a PTCA  one Stent in one , 2 stents in other.

In 2022, he developed flank pain , pedal edema for which he went local hospital and diagnosed as renal failure for which is taking dialysis since February. 


Past history  


K/C/O hypertension, diabetes mellitus since 1998.

N/K/C/O of epilepsy, Asthma,tb 


Treatment history  

He had history  of PTCA surgery.

Underwent surgery for hypertensive retinopathy,  glaucoma. 


Family history 

Not relevant 


Personal history  


Diet veg

Appetite  decreased 

B&B movements Irregular

Sleep Disturbed 

Addictions  he was drinker stopped drinking 3 yrs back

  Smoker and stopped 15 yrs back



Dinner at 7 pm 


Sleeps by 9 pm 



GENERAL PHYSICAL EXAMINATION 



Patient is conscious  not coherent not cooperative. Not well  oriented to time place person . Moderately built and nourished 



Pallor  absent



Icterus absent 



Cyanosis absent 



Clubbing absent 



Lymphadenopathy absent 



Edema absent 



Vitals 



Temperature  afebrile



PR  108 bpm



RR 29cpm



BP 110/70 mmHg 


Spo2 97% at RA



Systemic examination 


CVS- S1 S2 heard, no murmurs 


RS- BAE ,NVBS 


PA- Soft and non tender 


CNS - E3 V1 M4

           speech no response

           Power moving all 4 limbs

           Tone increased in all 4 limbs

       Reflexes 

                        B.     T.    S.     A.    K.   P

        R.             +      +    -        +     +     flexion

        L.             +       +    -        +    +      flexion 


Sensory -  can't be elicited 



Investigations  







Provisional diagnosis 

CKD


Treatment  

RT FEEDS - 100ml of milk 5th hrly and 500ml water 2nd hrly

Fluid and salt restriction.

Inj meropenem 500mg IV BD

Inj Lasix 40mg Iv BD

Inj nicardia 10 mg RT TID

TAB neomol 1gm IV SOS 

TAB Nodosis  500mg  RT TID

TAB dolo 600mg RT TID 

TAB snelcal 500mg RT OD

Cap BIO D3 RT  weekly once





Comments

Post a Comment

Popular posts from this blog

Image
 A 58 year old male, labourer by occupation, came to the OPD with the chief complaints of Shortness of breath since 30 days,which was worsened 1 day back(19/02/22), chest pain since 30 days ,facial puffiness since 30 days History of Presenting illness -   Patient was apparently asymptomatic 3 years ago then developed giddiness,  for which he went to a local hospital and was diagnosed as Hypertensive, for which he is taking T. Nicardia 10mg, T. Arkamine 0.1mg sos. Then 2 years back he  developed B/L pedal edema,  which progressed gradually to knees and  diagnosed with renal failure, started dialysis weekly twice. Since 4 months he developed left upper limb swelling and swelling at chest region,both of  which got  progressed to current size.  Back pain since 2 months, which got subsided on medication (T. Ultracet).  30 days back - he developed shortness of breath ,Grade II-III  which progressed to Grade IV since 30 days associated with orthopnea . Whereas from 4 days he developed right u
Read more

A 65yr old M with Hypoglycemia,Hypotension

Image
 A 65 yr old male patient, resident of miryalguda came with chief complaints of  Hypoglycemia. Pt came with  Hypoglycemia with Grbs 30mg/dl. Pt came to the surgery department with c/o multiple ulcers over lt leg since 6 months. Pt was apparently asymptomatic 6 months back then he developed 4 small ulcers of size 1x 1 cm initially, which was gradually increasing to attain present size.H/o fever which was on and off. Then he suddenly developed Hypoglycemic symptoms and became unconscious  and transferred to medicine department.No H/o trauma  H/o Fracture at left elbow joint which was ill treated - Non union of Fracture 30 yrs back. Pt is a K/C/O of DM and is on regular medication - T. Glimestarmil PO/OD Had H/o pulmonary cox 2 yrs ago. N/K/C/O HTN,Asthma,Epilepsy.  Married He worked as a Sarpanch in his village. Have Normal appetite with mixed diet and regular bowel and bladder movements.  No significant family history  General examination  Pt is c/c/c .  No pallor,Icterus, Clubbing,Cyan
Read more

1801006077 SHORT CASE

Image
 A 40 year old female patient ,hotel owner, resident of Narketpally came with chief complaints of Increased heartbeat since 6 months Breathlessness since 6 months HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic 6 months back then she developed palpitations which were sudden in  onset, gradually progressive and develops under stress, heavy work. It lasts for 2 to 3 min and relives on rest . Since the last 2 to 3 months she complains of increased frequency and intensity of palpitations. She also complains of breathlessness ( shortness of breath) since 6 months and it was gradually progressive from grade 1 (6 months back)to 3 (presently)and it relieves on rest. Patient also has fainting attacks , headache when there is delay in food intake or prolonged standing and it gets relieved on taking rest or food. PAST HISTORY Not a known case of Diabetes, Hypertension, Asthma, Tuberculosis,Epilepsy, Thyroid disorders. Has acidity from past 15 years. She develops burning sensation
Read more