A 67 year old male not responding to words,commands,unable to speak and swallow.

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


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