59M with Giddiness and gait disturbances with k/c/o DM



 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. 


CASE PRESENTATION

A 59-year-old male presented to OPD with chief complaints of 

giddiness since 10 days 

difficulty in walking since 10 days


Patient was apparently normal three years back where he developed generalised weakness associated with low-grade fever, tingling sensation of both hands, polyuria and polydipsia was diagnosed with diabetes and hypertension and currently on Tab. Glimiperide 1mg OD for diabetes and Tab. Telma H for Hypertension.

Known asthamatic since 40 years.

On examination

Patient is conscious coherent and cooperative well oriented to time place and person


At presentation 

BP : 140/100mmhg, PR : 98bpm, spO2 96% on RA.

CVS: S1, S2 heard. No murmurs 

RS : BAE + no crests

P/A : Soft and non tender, No organomegaly,  bowel sounds +

CNS : 



HMF intact, 


Tone : B/L upper limbs normal 

           B/L lower limbs hypertonia.


Power:        R               L

      UL        4/5              4/5

      LL        4/5              4/5


Reflexes : All DTR are absent with b/l plantar mute.

Heel knee : over shooting + (abnormal)


CBP :



CUE: 
















Outside CT scan report reveals hypodense lesions in B/L cerebellar hemispheres suggestive of Infarcts.


ECG : 



Treatment: 

Tab. Glimiperide 1mg OD

Tab. Ecosprin-AV OD

Inj. Optineuron 1amp in 100ml NS IV OD

Tab. Promethazine 25mg TID.

Neb with Duvolin 8th hourly, Budecort 12th hourly.

Physio therapy of B/L lower limbs.

Syp. Lactulose.

Vitals monitoring.











































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