A 38 year old male with c/o of unable to stand on his own,unable to eat on his own,urinary incontinence

 38 year old male with c/o unable to stand on his own,unable to eat on his own and urinary incontinence 

march 3,2023

M.sandhya 

roll no 94

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38 year old male who works in a mobile network company  by occupation and came to opd with

CHIEF COMPLAINTS;

 unable to stand on his own and unable to eat on his own since 20 days

urinary incontinence since 15 days

 

HISTORY OF PRESENT ILLNESS;

Patient was apparently asymptomatic 20 days back then 

he  suddenly developed inability to stand on his own and also inability to eat on his own,gradually progressive 

initially patient used to do his own activities but gradually stopped doing his work and got bed ridden

c/o urinary incontinence since 15 days before that patient informed about his urination but since 15 days he is passing urine involuntary

attenders also complain of patients self talking

(hallucinations -visual)

no h/o fever,SOB,chest pain,pain abdomen

slurring of speech since 15 to 20 days,last alcohol binge 20 days back

h/o similar complaints in the past in Nov 2022,he was taken to a local hospital with c/o weakness of lower limbs subsided on treatment 

h/o admission in dac,in our hospital 6 to 7 years back,stayed for 2 months and started consuming alcohol again 15 days after discharge 

PAST HISTORY;

N/k/c/o DM,HTN,TB,EPILEPSY, CVA,CAD,THYROID DISORDERS 

FAMILY HISTORY:-

insignificant 

PERSONAL HISTORY:-

DIET-mixed

APEPTITE- Lost since 15 days

BOWEL &BLADDER-Regular

SLEEP-Adequate.

ADDICTIONS- Alcohol regular 300 ml/day since 12 to 13 years

GENERAL EXAMINATION:-

Patient is drowsy, coherent,cooperative.

Well oriented to time place & person 

Moderate built and moderately nourished.

Pallor absent

No cyanosis, clubbing, icterus, LN

Vitals : 

Bp -130/70 mmhg

PR -86 bpm ;

RR : 18cpm

Spo2 : 99 on RA

GRBS:106 mg/dl

CNS examination:

SYSTEMIC EXAMINATION :

CNS EXAMINATION;

CNS:                 R                L

Tone-  UL         N                N

            LL    hypertoina hypertonia         

 Power-UL        5/5            5/5

             LL        5/5            5/5

 Reflexes- Biceps- +        +

                 Triceps- +       +

                 Supinator- +    +

                 Knee-    +       +

                 Ankle-  +          +

                 Plantar- flexion   flexion

Sensory examination: Normal

Rhomberg's negative

Cerebellum:

Nystagmus-absent

Tremors- absent

Finger nose test- normal

Dysdiadokinesia- absent

CARDIOVASCULAR SYSTEM:-

S1 S2 heard 

No murmurs.

RESPIRATORY SYSTEM:-

Dyspnea-absent

No wheeze

Breath sounds - vesicular

No Adventitious sounds 

ABDOMINAL EXAMINATION:-

No tenderness 

No palpable liver and spleen.

Bowel sounds - present.

INVESTIGATIONS:-

psychiatry referral taken i/v/o alcohol consumption. Advised

Tab.lorazepam 20 mg PO/OD

Inj.thiamine as per guided by physician

MRI      

             

03/03/2023

2D-ECHO

CHEST X-RAY

ECG

USG ABDOMEN;;

      

TREATMENT;

1. inj.thiamine 500 mg in 100 ml NS I.V /TID

2.Inj.optineuron 1 amp in 100 ml NS I.V/OD

3.I.V fluids 1 NS,1 RL @100 Ml/hour

4.GRBS monitoring 4th hourly