General medicine case presentation 6

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A 75 years old male patient came to casuality with the chief complaints of 

1) sudden onset of weakness in right upper limb & lower limb

 2) Deviation of mouth to the left.

3) Slurring of speech.

4)cough with sputum since 10 days.

HISTORY OF PRESENT ILLNESSES:-

Patient was apparently asymptomatic 2 days back, yesterday while he was taking his tea at 7 pm he noticed sudden weakness in his right upper & lower limb, deviation of mouth towards left and Slurring of speech.He phoned to his attenders ,upon their arrival his upper limb weakness was resolving & on bringing him to the hospital deviation of mouth resolved.

PAST HISTORY:-

He is a known case of diabetes & hypertension since 11 yrs and is on regular medication.

He had sudden onset of SOB & chest pain 10 years back and diagnosed as MI underwent PTCA ( percutaneous transilluminal coronary angioplasty)and is on Tab.Atorva 20 mg 100 pills medication till now.

Patient was a chronic cigar smoker for 40 yrs and stopped after PTCA.

Never visited the hospital except for regular diabetic checkup.

PERSONAL HISTORY:-

DIET:-mixed

APETITE:-normal

BOWEL movements:- normal

MICTURITION:-normal

Addictions:-

Chronic smoker for the past 40 yrs and stopped 10 yrs back.

No significant family history.

TREATMENT HISTORY:-

Patient is not allergic to any drugs.

GENERAL EXAMINATION:-

patient was coherent, cooperative and conscious.

Patient looks thin and weak.

No cyanosis,pallor, icterus, clubbing,lymphadenopathy.

VITALS:-

Temperature:- afebrile

SpO2:-97% at room air

Pulse rate:- 78/ min

Respiratory rate:-16 cpm

Bp:-150/100 mm Hg

SYSTEMIC EXAMINATION:-

CVS:-

S1&S2 heard

No murmurs.

RS:-

Treachea:- Central

No dysponea

No wheeze

Abdomen:-

Shape of abdomen:-scaphoid

Tenderness:-no

Liver:- not palpable

Spleen:- not palpable

CNS:-

Speech:- slurred

Cranial nerves:- normal

Motor nerves:-tone increased in right upper and lower limbs.

Sensory system:- normal

PROVISIONAL DIAGNOSIS:-

? Acute Mi

UMN facial palsy 

Hemiparesis ( resolved)

INVESTIGATIONS:-

HEMOGRAM:-

BLOOD GLUCOSE LEVELS:-

GLYCATED HEMOGLOBIN:-

RENAL FUNCTION TEST:-

LIVER FUNCTION TEST:-

TREATMENT:-  

Tab enalapril 5mg/po/OD 

Tab Atorvas 40mg /po/ h/s 

Tab Ecospirin 150mg /po/OD 

Tab Glimiperide 1mg 

Metformin 500mg /po/OD 

GRBS monitoring 6th hourly 

Syrup Ascoryl 10ml

Tab Clopidogrel 75 mg /po/ h/s