Patient came to the casuality with the chief complaints of
1. Generalised body pains
2. Vomitings
3. Slurring of speech
4. Not able to swallow solids or liquids
The patient was apparantly asymptomatic 4 days back. Then he developed generalised body pains, insidious in onset for which he took medicines from the local RMP. He had 4 episodes of vomiting, non projectile, non bilious, non foul smelling, no blood stain and had food particles as their content. Yesterday alone he had 3 episodes of vomitings, non projectile, non bilious, non foul smelling, no blood stain and had food particles as their content. Today morning he had sudden onset slurring of speech and was unable to swallow any solids or liquids.
Patient is having decreased ambulation. Has been walking with the help of a stick since 1 year.
K/C/O DM2 (since 20years)(on inj mixtard 35u - X - 30u)
Cervical spondylitis (since 10 years)
Used TB medication for 18 months. After starting TB medicines for 5 months he developed diminished vision(regained after 2 months)
decreased ambulatory, confined to bed
From 1 year patient is walking with stick
Personal history:
Appetite: Normal
Diet: Mixed
Bowel and bladder: Regular
Addictions: 4 years back alcohol(180ml/day), cigarette(80/day), now stopped
O/E
Patient is conscious coherent and cooperative
Vitals:
BP:130/70, Temp:98.4f, PR:100/min, RR:24/min, SpO2:92% on RA, GRBS: 557mg/dl
Cvs: S1,S2+
CNS:
1)Intellectual functions
-patient is conscious,oriented to time ,place and person
-memory-immediate,recent and remote memory present
-appearence-well kept
-speech-normal
2)cranial nerves
Olfactory-smell present on both sides
Optic-visual acuity -CF 6 metres
Visual field,colour vision,reflexes -normal
3,4,6 cranial nerves-ocular movements -present
Nystagmus,pros is,Diplopia-absent
Pupils are normal
Trigeminal -motor and sensory functions normal on both sides
Facial nerve
-deviation of mouth towards left side
-frowning present
-absent nasolabial folds on right side
-blowing and whistling absent
Taste sensation on anterior 2/3rd of tongue present
Corneal reflexpresent on both sides
Vestibulocochlear nerve-rinnes Weber,schwabach test Negative on both sides
Vagus and glossopharyngeal -uvula midline
Spinal accessory-shrugging of shoulders present
Hypoglossal-no deviation of tongue
3)Motor system
A)attitude and position-Normal
B)bulk-no wasting
C)tone-Rt Lt
UL N N
LL N N
D)power-
UL Rt Lt
-5/5 -5/5
LL -5/5 4/5
4)Reflexes
Superficial Rt Lt
Corneal +2 +2
Conjunctival +2 +2
Abdominal +2 +2
Deep Rt Lt
Biceps Hyperreflex
Triceps Hyperreflex
Supinator Hyperreflex
Knee Hyperreflex
Ankle Hyperreflex
5)Sensory system
Superficial -fine touch,temperature,pain -present
Deep-position,vibration,crude touch,stereognosis,2point discrimination- present
6)Cerebellum
Speech,nystagmus,ataxia,tremors,released reflexes absent
7)Coordination and gait
Finger nose test ,finger finger test,heel knee test-present
Gait -dragging type
Romberg test -negative
8)signs of meningeal irritation
Nuchal rigidity,kernigs and brudzinski’s sign - absent
Neck rigidity is present due to ossified posterior longitudinal ligament(cervical spondylosis
• Per abdomen :
Soft
Non tender
No organomegaly
Bowel sounds heard
INVESTIGATIONS:
1. ABG- ph;7.50
PCO2 : 30.1
PO2 : 76.8
HCO3 : 23.5
2. Blood urea:72
3.Sr.creatine : 2.3
4. LFT:
TB: 0.97
DB: 0.19
SGOT: 29
SGPT: 27
TP: 7.2
ALBUMIN: 3.8
A/G: 1.15
5. Sr.Elctrolytes:
Na+ : 136
K+ : 4.0
Cl- : 90
6. RBS: 412
7. Hemogram
HB:12.0
TLC:14,800
PCV : 34.1
MCV:71.6
MCH:25.2
PLT:4.42L
RBC: 4.46
8. URINE FOR KETONES: -VE
9. BLOOD GROUPING AND TYPING: O+VE
10. CUE:
Alb:+
Sugar:+++
Bile salt: nil
Pus cells: 3-4
Epithelial cells:2-4
RBC: nil
11.ECG
12. USG Abdomen
13. X-RAY chest
14. X-RAY Neck
15. CT Brain
http://pacs.kaminenihospitals.com:99/WADO/MetaData?aet=AEKIMS&studyUID=1.2.392.200036.9116.2.6.1.3268.2051739142.1630217943.758188&sessionKey=3403b2c0-14c1-4d65-a2e0-fe8ea4b0d219&src=Vijaya
16. Phantom pillow(indicative of cervical spondylosis)
Treatment given;
Day 0:
1. Inj.HAI 39ml +1ml HAI @6ml/hr til grbs is <200mg/dl
2. Tab.Ecospirin
3.tab.clopidogrel
4. Atorvastatin/49mg/Po/Od
5. GRBS 1hrly
Day1
1.Tab.Ecospirin
2.tab.clopidogrel
3. Atorvastatin/49mg/Po/Od
4. Inj. HAI/SC/TID (8am--X--8pm)inform sugars to icu pg
5. Inj NPH/SC/BD
6.TAB.ULTRACET 1/2 TAB PO QID
7.INJ.TRAMADOL 1Amp in 100ml NS IV SOS
8. IVF- NS @75ml/hr
9.GRBS 1hrly
Day 2
1.Tab.Ecospirin
2.tab.clopidogrel
3. Atorvastatin/49mg/Po/Od
4. Inj. HAI/SC/TID (8am--X--8pm)inform sugars to icu pg
5. Inj NPH/SC/BD
6.TAB.ULTRACET 1/2 TAB PO QID
7.INJ.TRAMADOL 1Amp in 100ml NS IV SOS
8. IVF- NS @75ml/hr
9. Tab.Pregablin 75mg/po/HS
10. GRBS 1Hrly
Day3
1.Tab.Ecospirin
2.tab.clopidogrel
3. Atorvastatin/49mg/Po/Od
4. Inj. HAI/SC/TID (8am--X--8pm)inform sugars to icu pg
5. Inj NPH/SC/BD
6.TAB.ULTRACET 1/2 TAB PO QID
7.INJ.TRAMADOL 1Amp in 100ml NS IV SOS
8. IVF- NS @75ml/hr
9.Tab Pregablin 150mg/PO in the morning
10.Tab.Pregablin-M 75mg/po/HS
DAY 4
SUBJECTIVE:
Neck and shoulder pain
Objective:
BP:150/60mmhg
PR:97bpm
RR:21/min
GRBS:
367 --8am--15HAI,12NPH
307--1pm--20HAI
217--8pm--10HAI,20NPH
ASSESSMENT:
Rt Facial Hemiparesis Lt Facial Nerve Palsy,
Peripheral Neuropathy (?ATT Induced)
K/C/O DM-II with Uncontrolled Sugars
De-novo HTN(?post pulmo tb)
Plan:
1.Tab.Ecospirin
2.tab.clopidogrel
3. Atorvastatin/49mg/Po/Od
4. Inj. HAI/SC/TID (8am--X--8pm)inform sugars to icu pg
5. Inj NPH/SC/BD
6.TAB.ULTRACET 1/2 TAB PO QID
7.INJ.TRAMADOL 1Amp in 100ml NS IV SOS
8. IVF- NS @75ml/hr
9.Tab Pregablin 150mg/PO in the morning
10.Tab.Pregablin-M 75mg/po/HS
11. Fentanyl 1ml+4ml NS
Opthalmic Referral done for Diabetic retinopathic changes
X-ray Hip
X ray LS spine
Day 5:
A Case of 74yr old male
SUBJECTIVE:
Neck and shoulder pain
Objective:
BP:120/40mmhg
PR:92bpm
RR:21/min
GRBS:
119 --8am--10HAI
189--10am--20NPH
159--1pm--10HAI
129--8pm--10HAI,20NPH
ASSESSMENT:
Rt Facial Hemiparesis Lt Facial Nerve Palsy,
Peripheral Neuropathy (?ATT Induced)
K/C/O DM-II with Uncontrolled Sugars
De-novo HTN(?post pulmo tb)
Spondyloarthropathy with radiculopathy
Sacroileitis
Cervical OPLL(ossification of posterior longitudinal ligament)
Plan:
1.Tab.Ecospirin po/Od
2.tab.PCM 650mg/po/TID
3. Amlong 2.5mg/Po/Od
4. Inj. HAI/SC/TID (10U--10U--10U)inform sugars to icu pg
5. Inj NPH/SC/BD (20U--X--20U)
6.TAB.ULTRACET 1/2 TAB PO QID
7.INJ.TRAMADOL 1Amp in 100ml NS IV SOS
8. IVF- NS @75ml/hr
9. TAB. Benadon 40mg/po/od
10.Tab.Pregablin-M 75mg/po/HS
11. INJ. Tramadol 1amp in 100ml NS/SOS
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