A case of 57 year,Male with Giddiness , difficulty in walking swaying to right

  92 Sneha Nadipi

5th semester 

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*️⃣CASE SENERIO:

🌡CHIEF COMPLAINTS:

 Giddiness since 4 days

Difficulty in walking since 4 days 

Swaying to right since 4 days

🌡HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 days back and then developed pain and swelling of bilateral lateral malleolus for which he visited local RMP for which he received an injection (unknown) followed by which he developed excessive sweating and next day he developed excessive sweating and giddiness and difficulty to walk associated with swaying to right for which  he went to local hospital and CT was done and medication were given and referred for further management and here around 6 PM he perceived objects as two(diplopia) adn it got resolved on its own after 30 minutes.

📍BP at time of presentation to hospital - 170/100 mmHg

🌡PAST HISTORY:

 K/c/o HTN (greater than 1 year) and for which he used medication for 3 months and stopped.

 Not a known case of DM/TB/Asthma/Epilepsy/CAD/CVA/Thyroid disorders.

🌡PERSONAL HISTORY : 

- Married 

-Mixed diet:Non-vegetarian

- Apettite loss:No

- Bowel and bladder movements : Normal

-No H/O known drug allergies

Addictions:

-Alcohol : Chronic alcoholic 20 years 90ml

                 (stopped 2 years ago)

Smoking: Beedi smoker 2 packets per day (20 in                          number)

🌡FAMILY HISTORY 

     Insignificant

🌡PHYSICAL EXAMINATION : 

A) GENERAL EXAMINATION

Patient is consious,coherent and cooperative,well built and nourished

 Pallor- No

lcterus-No

Cyanosis-No

Clubbing of fingers/toes- No

Lymphadenopathy-No

Oedema of  feet- No

Malnutrition -No

Dehydration -No

No H/O, cyanosis , lymphadenopathy , clubbing of fingers or toes , dehydration

BP-170/100 mmHg 

Pulse rate-86 bpm

Respiratory rate-16 bpm

Temperature -Afebrile

SpO2-98%

🌡SYSTEMIC EXAMINATION 

B) CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

C) Respiratory System 

- Dyspnea : NO

- Wheeze :No

-Position of trachea -Central

-Breath sounds -Vesciular 

D) ABDOMEN 

--Scaphoid 

E)CNS:-Normal

1. Higher Mental Function:-

Alert and conscious 

Normal speech

2. Cranial nerves -Normal

 all cranial nerves

3. Motor system - attitude

                                             Rt.              Lt. 

                      •Reflexes.  B +++          +++

                                         T + +             +

                                         S +++          +++

                                         K +++         +++

                                         A ++.          ++

                     Plantars-flexors 

             Rt. -flexors.  

             Lt-Mute

4.Cerebellar signs:

finger -Nose  in coordination -No

Knee-heel in coordination -No

Swaying to right with eyes open

Dysdiadochokinesia-Present

5.Gait- Broad based

6.Nystagmus- Horizontal present 

PROVISIONAL DIAGNOSIS 

   Acute Cerebellar infarct

                            

    Treatment:

On 4/9/22

Tab. ECOSPRIN 75mg

TAB CLOPITAB 150 mg

TAB ATROVAS 80 mg

On 5/9/22

Tab. ECOSPRIN 75mg

TAB CLOPITAB 150 mg

TAB ATROVAS 80 mg

INJ OPTINEURON 1 amp/100 ml iv