86 year old male with slurring of speech and hypertonia

Kausalya Varma, MBBS 9th semester

Roll no: 59

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AN 86 YEAR OLD MALE WITH SLURRING OF SPEECH AND HYPERTONIA 

CASE:

An 86 year old male came with the complaints of slurring of speech and excessive sleep for the past 4 days and hypertonia of all four limbs for the past 4 days. 

HISTORY OF PRESENTING ILLNESS:

- The patient is a retired bank manager residing in ramanapeta and he was brought to the casualty two days back with the complaints of drowsiness, slurred speech, inability to identify people for the past four days.

- He also presented with hypertonia of all four of the limbs for the past four days.

- The patient was apparently asymptomatic 20 days before the day of admission, when he developed a bilateral swelling of the knee joint for which he was taken to the hospital near, where he was given conservative management. 

- Patient had decreased appetite and decreased food and water intake for the past 20 days as observed by the patients attenders.

- 3 months back the patient had observed a blackish discolouration of the fourth toe of the right foot for which he was advised amputation and was operated on. 

 

PAST HISTORY:

Medical history-

-The patient is known case of Diabetes Mellitus since the past 5-6 years and is on medication.

-He is a known case of hypertension for the past 30 years for which he is on medication. for which he is taking medication.

-Patient is suffering from rheumatoid arthritis for the past 15 years and is not on any medication.

Not a known case of tuberculosis, asthma, epilepsy, CAD

Surgical history-

There is no relevant surgical history for this patient 

PERSONAL HISTORY:

Diet- Non Vegetarian 

Appetite- Decreased since the past 20 days 

Sleep- Increased since past 20 days

Bowel and Bladder movements-  Urine output decreased for past few days, bowel movements are normal

Addictions- Patient consumes alcohol daily (90ml per day)

Family history- not significant 

GENERAL EXAMINATION:

The patient was conscious, not coherant, co-operative and not well oriented to time, place and person. With prior consent, patient was examined in a well lit room, lying down on the bed. He is moderately built and moderately nourished.

Pallor- Present

Icterus- Absent 

Clubbing- Absent

Cyanosis- Absent

Lymphedenopathy- Absent

Edema- Present, on the lower limbs, pitting type 

Koilonychia- Absent

VITALS- 

(At admission) 

Temperature- 98.4 F

Pulse rate- 84 bpm

Blood pressure- 140/90 mmHg

Respiratory rate- 36 cpm

Sp02 at room temp- 99%

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION-

INSPECTION:

Shape – scaphoid, not distended 

Flanks – free

Umbilicus – Central, inverted

Skin- LSCS scar is present, no sinuses, striae are seen

Dilated veins – absent 

Movements of the abdominal wall with respiration is present 

No visible gastric peristalsis or intestinal peristalsis

PALPATION:

Superficial Palpation – No local rise of temperature or tenderness 

Deep Palpation-

Liver-

It is palpable in the  Right hypochondrium about 5 cms below the Right costal margin in the Mid clavicular line and 2 cms in the midline from the Xiphisternum which moves with respiration and is firm in consistency with a 

Smooth surface and a rounded edge. The upper border of the liver is not palpable.

Spleen-

Spleen is palpable in the Left Hypochondrium, enlarging towards the Right Iliac Fossa

2 cms below the Left Costal Margin in the Mid clavicular line, which moves with respiration and is firm in consistency with a Smooth surface and a rounded edge

Kidney-

It is not palpable 

- No other Palpable swellings in the abdomen.

PERCUSSION:

Percussion of Liver for Liver Span- The liver span is 16cm from midclavicular line and 7cm from the sternum, dull percussion 

Percussion of Spleen- Dull note in percussion  

There is no fluid thrill, shifting dullness

AUSCULTATION:

Bowel sounds are heard

RESPIRATORY SYSTEM-  

Inspection-

Chest is bilaterally symmetrical

The trachea is positioned centrally

Apical impulse is not appreciated 

Chest moves normally with respiration

No dilated veins, scars or sinuses are seen

Palpation- 

Trachea is felt in the midline 

Chest moves equally on both sides 

Apical impulse is felt in the fifth intercostal space 

Tactile vocal fremitus- appreciated 

Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.

Auscultation-

Normal vesicular breath sounds are heard

No adventitious sounds heard

CARDIOVASCULAR SYSTEM- 

Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 

Palpation-

Apical impulse is felt in the fifth intercostal space, 2 cm away from the midclavicular line

No parasternal heave or thrills are felt 

Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 

CENTRAL NERVOUS SYSTEM-

HIGHER MENTAL FUNCTIONS:

Patient is Conscious, well oriented to time, place and person.

All cranial nerves - Intact

Motor system

                              Right.                  Left

BULK 

Upper limbs.        N.                         N

Lower limbs         N.                         N

TONE

 Upper limbs.       N.                        N

 Lower limbs.      N.                        N

POWER

 Upper limbs.      5/5.                    5/5

 Lower limbs      5/5.                    5/5

Superficial reflexes and deep reflexes are present, normal

Gait- Could not elicit, the patient was not able to get off the bed

No involuntary movements

Sensory system- All sensations (pain, touch, temperature, position, vibration sense) are well appreciated

INVESTIGATIONS

The routine investigations done for this patient include,

12/01/2022

ABG Analysis-

PH- 7.40

PC02- 21.3

P02- 54.7

HC03- 13.0

Serum LDH- 346 IU/L

LFT- 

Total bilirubin- 4.7 mg/dl

Direct bilirubin- 2.57 mg/dl

AST- 102

ALT- 35

ALP- 144

Total proteins- 5.6

Albumin- 2.3

A/G- 0.72

RFT- 

Urea- 45 mg/dl

Creatinine- 3.2

Uric acid- 8.0

Ca- 10 mg/dl

Na- 136

P- 4.4 mg/dl

K- 4.8 meq/lt

Cl- 90 meq/lt

Coagulation profile- 

PT- 20

INR- 2.4

aPtt- 41

Complete urine exam- 

Albumin- ++

Sugar, bile salts, bile pigments- normal

Pus cells- 10-12 

Epithelial cells- 4-5

RBC- 3-4

Casts- granular casts are present 

Complete blood picture-

Reticulocyte count- 0.5%

Hb- 5.7

TLC- 18400

N/L/E/M- 93/4/1/2

PLT- 65000

A Fever chart of the patient has been drawn up, as seen below

PROVISIONAL DIAGNOSIS-

Fever along with hepatosplenomegaly

Pre renal AKI

TREATMENT-

05/03/2022

At 11:10pm

On examination,

Patient is drowsy and irritable

Bp:140/90 mmhg

PR: 84 bpm

Spo2: 99%@room air

RR 18

Muffled heart sounds heard

Normal vesicular breath sounds heard 

Treatment-

- Head end elevation up to 30 degrees 

- IVF- 3% NaCl at 4 ml per hour (to be increased or decreased according to the electrolytes)

- Inj Pantop 40mg/IV/OD

- Inj Neomol 100ml if temp increases more than 101.1F

- RT feeds- 100ml milk and 100ml free water 

- Fever charting hourly 

- monitor vitals every two hours 

- Inj Thiamine 1 amp in 100ml IV/BD

06/03/2022

At 7am

On examination,

Patient is conscious and drowsy

Bp:140/90 mmhg

PR: 101 bpm, regular, normal volume 

GRBS- 97 mg/dl

Spo2: 99%@room air

RR 18cpm

He had a fever spike and a cough 

Treatment-

- Head end elevation up to 30 degrees 

- IVF- 3% NaCl at 4 ml per hour (to be increased or decreased according to the electrolytes)

- Nebuliser with salbutamol - 2 resipules every six hours

- Inj Pantop 40mg/IV/OD

- Inj Neomol 100ml if temp increases more than 101.1F

- RT feeds- 100ml milk and 100ml free water 

- Fever charting hourly 

- monitor vitals every two hours 

- BP, PR, sp02 chatting every 2 hours 

- Inj Thiamine 2 amp in 100ml IV/BD

- Mega heal ointment for L/A

- Ascoryl syrup RT/BD

- Inj Monocef IV/BD

06/03/2022

At 10 pm

On examination,

Patient is awake and confused 

Bp:150/90 mmhg

PR: 102 bpm, regular, normal volume 

Spo2: 98%@room air

RR 18cpm

Temp- 101.1F continuous 

- Drowsiness decreased, difficult in swallowing, epigastric fullness(indigestion) 

Treatment-

- Continue treatment 

- Consider Inj magnesium 2g/IV/stat

- Syrup Potchlor 10 ml in 1 glass of water PO/BD for 2 days 

07/03/2022

At 7am

On examination,

Patient is conscious and drowsy

Bp:140/90 mmhg

GRBS- 132 mg/dl

PR: 98 bpm, regular, normal volume

Spo2: 99%@room air

Temp- 99.1 F

RR 18cpm

He had a fever spikes

Treatment-

- Head end elevation up to 30 degrees 

- IVF- 3% NaCl at 4 ml per hour (to be increased or decreased according to the electrolytes)

- Nebuliser with salbutamol - 2 resipules every six hours

- Inj Pantop 40mg/IV/OD

- Inj Neomol 100ml if temp increases more than 101.1F

- Fever charting hourly 

- monitor vitals every two hours 

- BP, PR, sp02 chatting every 2 hours 

- Inj Thiamine 100 mg IV/BD

- Mega heal ointment for L/A

- Ascoryl syrup RT/TID

- Inj Monocef 1g IV/BD

- oral suctioning 2 hourly 

- Tab Tolvaptan 15mg PO/BD