85 M WITH ALTERED BEHAVIOUR WITH TYPE 2 DIABETES MELLITUS SINCE 20 YEARS
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
This is a case of 85 year male who came with complaints of :
Altered behaviour since day before yesterday night
No food intake since one day (last food intake on4/5/23)
No history of fall, seizures, loss of consciousness, fever
Patient was apparently asymptomatic till 4/5/23 then he had altered behaviour since evening.
Patient attenders complaints of inappropriate sentences and behaviour (hallucinations)by the patient.
Past history:
K/C/O DM 2 since 20 years
History of similar complaints in the past in 2021 . CSF ANALYSIS 14-4-21
Colour - colourless.
Appearance - clear.
Quantity -1.5 ml.
Total count - 1 cells/cumm.
Lymphocytes - 100%.
Neutrophils - nil.
RBC - nil.
Others - nil.
Glucose - 86 mg/dl.
Proteins - 42 mg/dl.
Chloride -119 mmol/l.
H/o admission in the past 5 years back due to decreased urine output
Not a k/c/o CAD,CVA,ASTHMA,EPILEPSY.
PERSONAL HISTORY:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder: normal
Addiction:H/o bidi smoking (3-4 bidis/day)
H/o alcohol consumption 90 ml whiskey once or twice a month since 20 years
DAILY ROUTINE:
Patient wakes up at around 6 am then does his daily morning activities and has his breakfast at 7am which is usually idli or porridge .
He was a farmer but stopped working 10 years ago as his children were working and earning also he was becoming tired after the work due to old age.
He stays at home and does his daily works. He has his lunch at 3 pm and dinner at 9 pm after that he sleeps.
GENERAL EXAMINATION:
Patient is drowsy, incoherent
Vitals:
BP 170/100 MMHG
PR 97 BPM
RR 24/MIN
GRBS 192 MG/DL
SpO2 98% ON RA.
GCS - E4V3M6
No pallor,icterus, cyanosis, clubbing, lymphadenopathy , edema.
Systemic Examination-
Cvs-S1,S2 +
No Murmurs
Rs-BAE+
NVBS Heard
P/A-soft
Non tender
CNS EXAMINATION:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION : Normal
MOTOR EXAMINATION
RT. LT
POWER - UL 5/5 5/5
L L 5/5 5/5
TONE. - UL N N
LL. N N
REFLEXES RT LT
biceps 2+. 2+
Triceps 1+. 1+
Supinator 1+. 1+
Knee 2+. 2+
Ankle. 2+. 2+
Plantar B/L flexion
CEREBELLAR FUNCTION
No meningeal signs were elicited
INVESTIGATIONS:
6-5-23
DIAGNOSIS:
ACUTE CVA.
ACUTE INFARCT OF RIGHT SUPERIOR VERMIS AND SUPERIOR ASPECT OF CEREBELLUM WITH VASCULAR DEMENTIA , K/C/O TYPE 2 DM SINCE 20 YEARS
Treatment:
Inj.OPTINEURON 1 amp in 100 ml NS IV/OD
Inj.THIAMINE 100 mg IV/BD
Inj.HAI SC/TIC acc to GRBS.
RT FEEDS :
200 ml milk 4th hrly.
100 ml water 2 nd hrly.
TAB.ECOSPIRIN GOLD PO/HS
VITALS AND GRBS MONITORING.
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