65M with Recurrent CVA with visual hallucinations and k/c/o pulmonary Koch’s

 A 65-year-old male patient with known case of recurrent CVA presented with complaints of seen the faces, increased appetite and urinary incontinence since 2 months

Visual Hallucinations are sudden in onset associated with the ringing sensation in ears and hearing voices from surroundings

Patient was apparently a symptomatic six years back then he developed generalised weakness and giddiness for which he went to local doctor and diagnosed with diabetes and on OHA, then few months later he diagnosed with hypertension and on atenolol 50mg since 3yrs

History of first CVA attack 5 years back for which she went to hospital and managed conservatively and on dual antiplatelet TS for few weeks. Then 4 years back he developed low-grade fever associated with productive cough and generalised weakness. For which he was diagnosed with pulmonary tuberculosis and on ATT for 6 months.

Then he developed second attack of CVA 8 months back for which he took some herbal medication for 3 months and recovered spontaneously.

Patient complains of generalised weakness with loss of appetite since 3 months associated with decreased interest in doing work, frequently irritability and anger outburst over wife. Patient seeing sparklings, Seeing familiar faces group of people briefly for 15 to 20 mins and later they disappear, occassionally he will try to communicate with them but get no response from them since 3 days 

H/0 discord with son regarding his health condition 2 months back since then patient felt he is dependent on family members , unable to hold household work due to illness so he felt depressed and feels to die than being burden to family.


Hypertensive episode 4 days back 

Pt unable to speak and move durring that episode took treatment at local hospital and discharged after 2 days as patient felt better 

Hypoglycaemic episodes 3 days back where GRBS was dropped to 50mg%.

H/o episode of seeing people , talking to self , wanderings outside with sleeplessness 3 days back


Past h/o:

History of similar episodes in past 

K/c/o DM since 6 yrs and on OHA

K/c/o HTN since 6 yrs and on Atenolol 50mg 

N/k/c/o asthma 


PERSONAL HISTORY:

Mixed diet

Appetite decreased

Sleep inadequate

Bowel movements regular 

Alcoholic abstinence 2 years 


O/E 

Patient is conscious , coherent, co operative

Afebrile

Bp 130/80 mmhg

Pr 90bpm


No Pallor 

No icterus

No cyanosis 

No clubbing 

No edema 


CVS - No scars 

            Apex beat @ 5th ICS medial to mid clavicular line

            S1 & S2 heard 

P/A - soft & nontender

CNS : 


                                  Right                Left

Bulk :                
      Upper limb         Normal            Normal   .         
    Lower limb .        Normal.           Normal

Tone: 
      Upper limb:.     Normal.         Normal .
      Lower limb:.     Normal.         Normal .

Power:
      Upper limb:.     4/5.               4/5
      Lower limb:.     4/5.                4/5
Hand grip :             100% .           100%
 following commands
 
Motor system 
Reflexes:  
   Superficial reflexes: normal
   Deep tendon reflexes: 
      Biceps:.            -                 -
      Triceps:.           -                  -
      Supinator:.        -                  -
      Knee:.                 -                 -
      Ankle:.                -.                 -
      Plantar:.         Flexor             Flexor

Sensory system:        right         Left
                 
                Fine touch    +         +
               Vibration      +             +
            Position sense +         +
           Crude touch      +         +
       pain and temperature +      +

Rhomberg's - absent

Cerebellum: 
Nystagmus -ve
Pendular knee jerk -ve
Rebound phenomenon -ve
Dysdiadochokinesia -ve
Finger nose incoordination-ve
Finger finger incoordination-ve


Cranial nerve examination:
  I : intact
II : visual acuity 6/6
      Colour vision normal
III,IV,VI : normal pupil size
                No nystagmus,ptosis,eyemovements normal
V: Sensory - normal
    Motor - normal
Corneal & conjunctival reflexes - normal

Vll: No Deviation of angle of mouth towards right, Able to close eyes.
frowning present on both sides of forehead 

VIII : normal.
IX,X: Uvula- visualised,gag reflex + 
XI: normal
XII: tongue- tone normal,no deviation

ANS:regular bladder movements (incontinance +). No sweating and palpitations.

 Meninges: no signs of meningeal irritation(fever, headache, neck stiffness, nausea and vomitings)

RS -  shape of chest - obese

                                    BAE+


INVESTIGATIONS:











































TREATMENT GIVEN :

TAB. ECOSPRIN 75MG OD

TAB. CLOPITAB 75MG OD

TAB. ATORVAS 40MG HS OD

TAB. TELMA 40MG OD

TAB. PAN 40MG OD

TAB. LORA 2MG SOS

TAB. NEXITOFORTE PO HS (Escitalopram 10mg + Lonazepam 0.5mg)

TAB. NITROFURONTOIN 100MG BD

INJ HAI SC TID According to Sliding Scale

TAB. BPLEX FORTE PO OD


DIAGNOSIS:

RECURRENT CVA WITH ACUTE INFARCT IN FRONTAL LOBE & GENU OF CORPUS CALLOSUM WITH K/C/O HTN & DM WITH MODERATE DEPRESSION WITH ?DIABETIC NEPHROPATHY WITH OLD PULMONARY KOCHS.


Home death after 1-1/2 month



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