A 57 year old male presented with giddiness and inability to left leg

A 57 yr old male auto driver  resident of gundlasingaram came to the opd with chief complaints of 

• Giddiness since 4days

• Inability to move his left leg.

• falling to right side since 4days.

• Sweating,vomitings with Sbp of 235mmhg 

HISTORY  OF PRESENT ILLNESS 

Patient was apparently asymptotic  2years back after that he was diagnosed with Hypertension for which took medication ,after 3 months he discontinued the medication. 

4 days back he developed pain and swelling around  lateral malleolus bilaterally for which he went to a local hospital and took an injection after which he developed excessive  sweating,next day again he developed excessive sweating ,giddiness and was unable to move his left lower limb.He was Swaying to right side for which he went to local hospital and got referred  to this hospital. 

HISTORY OF PAST ILLNESS 

Not a known case of DM , epilepsy, Asthma, tb, CAD

H/o swelling in sacral region that is in between the buttocks 5years back.

H/o polyps in the nose (bilateral)

TREATMENT HISTORY 

H/o Surgery for swelling in the sacral region 5 years back.

H/o surgery for polyps in nose on both sides ( bilateral).


PERSONAL HISTORY  

Diet mixed 

Appetite normal

B&b movements - h/o Constipation since 4 years

Sleep adequate 

Addictions smoker : Smokes Bidi - 2 packs (containing 40 ) per day since 20 years

                      Chronic Alcoholic for 30 years stopped 2 years back


FAMILY HISTORY

Not significant 

GENERAL PHYSICAL EXAMINATION 

Patient is conscious , coherent ,cooperative. Well  oriented to time place person . Moderately built and nourished

Pallor  absent

Icterus absent 

Cyanosis absent 

Clubbing absent 

Lymphadenopathy absent 

Edema absent 


Vitals  

At the time of admission 

Temperature  98.6°f

PR  86bpm 

RR  16cpm 

BP 170/100mm Hg

Spo2 98% at RA 

GRBS 110 mg%

On 13/9/22 

PR  82bpm 

RR  18cpm 

BP 170/100mmHg


Systemic examination  

CVS- no thrills, s1 s2 heard, no murmurs  

RS - BAE+, 

        No h/o dyspnea

       No h/o wheezing

       Trachea central

        Adventurous sounds - none 

CNS - pt is conscious 

          Normal speech

          Neck stiffness -

           Kernigs sign -

          Cranial nerves intact

          Sensory system  intact

         Power 

                          Rt.               Lt

           UL.         5/5.           5/5

           LL.           5/5.          5/5

    TONE

             UL.            N.         N

             LL.             N.         N 

GLASSGOW  SCALE  :  E4 V5 M6 

Gait : broad based

Nystagmus  + (Horizontal) 

Finger nose In coordination -

Knee heel in coordination  -

REFLEXES  :    Exaggerated 

                 B.            T.             S.        K.       A 

Rt.            +++       ++           +++     +++     ++

Lt.           +++          +           +++      +++     ++  

Plantars -  flexor : Rt

                    Mute : Lt 

P/A - soft and non tender ,bowel sounds heard

PROVISIONAL DIAGNOSIS 

ACUTE INFERIOR CEREBELLAR INFARCT 

TREATMENT 

•  T. ECOSPIRIN 75mg /po/od

• T. Clopitab 150mg/po/od

• T.Atorvas 80mg /po/od

• T.Telma po/od

• Inj Optineuron  1amp in 100ml NS /od

• Spinfree /op/od

• T.clnod /po/od/evening

• T.Arkamime 0.1ng po/od

              


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