A 45 year old male came to the casuality with chief complaints of slurring of speech since 4 days, difficulty in swallowing since 4 days.
DAILY ROUTINE:
Patient is a construction worker, he goes to work early in the morning along with his wife. They work together, have lunch in the afternoon and go back to their house by evening or sometimes late in the night. Patient is married for 20 years now and has three children.
HISTORY OF PRESENTING ILLNESS AND PAST HISTORY:
Patient was apparently asymptomatic four years ago when had history of trauma to right nail and in view of delayed healing they got tests done and was diagnosed with Diabetes Mellitus and was started on oral hypoglycemic drugs. But sugars were not controlled and high in reports and hence patient was advised to take H.mixtard insulin 24U-16U. But patient takes it irregularly
Patient's wife c/o patient taking large quantities of food and is always hungry (1/4-1/2 kgs rice intake daily) ? Polyphagia
On further asking he gives even history of polydypsia and polyuria. Gets up approximately 5-6 times in the night for micturition.
Patient also gave a history of generalized weakness since two months.
Since 8 months patient c/o increased frequency of stools and loose watery stools 6-8 times /day, small quantities, Not associated with pain abdomen.No mucoid stools , non bloody. No vomitings.No decreased urine output back then.
Since 6 months c/o incontinence of stools and urine . Patient attenders gives history of passage of urine in between before reaching washroom ( overflow incontinence), bed wetting +
Now since 1 week decreased stool frequency Since 10 days patient c/o generalised weakness and unable to get up from bed. Walks or goes to washroom with support of attenders.
Patient also developed dysphagia for liquids since 4 days which was insidious in onset and did not progress.
No h/o weakness of limbs, deviation of mouth, loss of consciousness, seizures. No h/o headache.
PERSONAL HISTORY:
His apetite is normal. He takes mixed diet.
Patient is chronic alcholic consumes 180ml- 1 full bottle of whiskey since 20 years, and chronic smoker- beedis 20/ day
No known allergies.
GENERAL EXAMINATION
Patient is conscious and is confused.
Pallor, icterus, Lymphadenopathy, edema, cyanosis, clubbing- Absent.
Patient is afebrile.
BP-110/70mmhg
PR-105/min
SYSTEMIC EXAMINATION:
CVS:S1,S2+
R.S:BAE+NVBS
P/A: soft,non tender(stools-)
CNS: HMF
oritentation to person, place+
memory: recent and remote intact+
speech:dysarthria
CRANIAL NERVES:
II - Pupils - NSRL
CF -3 m
III,IV,VI - EOM INTACT
V - Corneal and conjunctival relfex intact
VII - ABLE to close eyes completely. No lagopthalmos
No deviation of mouth.
IX - Gag reflex absent
X -Deviation of uvula to right side.
SLURRED SPEECH present .Nasal twang present.
XII - NO Tongue deviation, fasciculations .
motor :tone :normal for all four limbs
power:3+/5 in all four limbs
REFLEXES: absent, B/l plantars: withdrawal
sensory: decreased fine touch in B/l LL upto L4.
INVESTIGATIONS:
On 16/11/21
DIAGNOSIS -
1) Dysphagia to liquids (?oral candidiasis) along with
Slurring of speech - ?Bulbar palsy - secondary to ? Acute CVA / ? GBS .
2) Bowel amd bladder incontinence secondary to ??diabetic autonomic neuropathy .(? over flow incontinence)
3) Chronic diarrhoea /osmotic diarrhoea secondary to ? chronic pancreatitis /uncontrolled sugars.
4) ??Delirium secondary to alcohol withdrawal
5) Hypokalemia under evaluation.(3.2- s. potassium)
6) Diabetic neuropathy
7) Uncontrolled sugars - Type 3C diabetes
8) Chronic alcoholic and smoker .
TREATMENT GIVEN:
1.RT Feeds Milk,free water 100ml 4th hrly
2.IVF -NS,RL @100ml/hr
3.Inj.THIAMINE 100mg in 100ml NS/IV/TID
4.Inj.PAN 40mg IV/OD
5.Inj.ZOFER 4mg/IV/TID
6.Tab.FLUCONAZOLE 100mg/RT/OD
7.Syp.POTKLOR 15ml in one glass of water
PO/BD
8.Inj.HAI S/C acc to GRBS
9.GRBS charting 6th hrly
10.BP/PR/TEMP CHARTING 4TH HRLY
11.STRICT I/O MONITORING
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