A 65 year old male with SOB

 1 st August,2022.

A 65 year old male patient from Gundrampally village, Chityala district who used to be a toddy climber by occupation came to the casuality with


C/o Shortness of breath since 3 days


Associated symptoms are 


Weakness in left upper limb and lower limb since 8 days


Difficulty in walking since 8 days


Involuntary defecation and micturition since 5 days




History of presenting illness


As explained by the patients' younger son


Patient was apparently asymptomatic 10 years back then one day early in the morning while waking up he noticed weakness in the left upper limb and lower limb and couldn't support himself properly.

2 days later he started using Ayurvedic medicine for the weakness, which progressively improved and he got completely alright within a month and got back to his daily routine


Patient had a normal life style until 8 days back. 


8 days back at 12 am patient woke up to micturate and noticed that he is having a similar weakness in the left upper and lower limb like previous and couldn't support himself. 


5 days back he started passing loose stools and micturating involuntarily but he had knowledge of passing them yet couldn't hold them


Patient conscious during all these events


They visited a local RMP doctor for weakness and difficulty in walking for which the RMP doctor infused IV potassium. 


The following night patient woke up with grade 4 shortness of breath associated with palpitations at around 12 am for which he was brought to the hospital. 


Patient was conscious at the time of admission but gradually felt drowsy and now the patient can listen to us and respond through actions but can not speak. 




Past history


K/c/o Hypertension since 10 years and was on regular medication( T. Atenolol 50 mg po OD) until 2months back when he started taking meds irregularly


Not a k/c/o Diabetes mellitus, Tuberculosis, Asthma, Epilepsy, CAD. 




Personal history


Patient had a good appetite with a mixed diet involving mostly rice and non vegetarian food. 


He sleeps for 7 hours from around 10pm to 5 am but wakes up to smoke beedi multiple times during night. 


Bowel and bladder movements irregular


Has a habit of smoking since many years and smokes nearly 30 beedis in a day daily


Occasional alcoholic. 




Family history- No other family members have similar complaints. 




Treatment history - Tab. Atenolol 50 mg OD for the past 10 years. 




General physical examination


Patient is drowsy


No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, edema. 


Vitals


Temperature - Afebrile currently but had a fever spike during night. 





Pulse - 110 bpm

Respiratory rate - 20cpm

Blood pressure - 120/70 mmHg

SpO2 - 97%

GRBS - 218 mg/dL



Systemic examination


Respiratory system - Shortness of breath grade 4, BAE  present with Inspiratory crepitus and expiratory ronchi


CVS - S1, S2 heard. 


Abdomen - Soft, Non tender


CNS - patient is drowsy and arousable 


GCS - E2V2M4


Power                Rt              Lt

  Upper limb    4/5            0/5

  Lower limb    4/5            0/5


Tone                     Rt                  Lt

    Upper limb      Normal    Decreased

    Lower limb     Normal    Decreased


Reflexes                 Right              Left


   Biceps                   ++                   ++

   Triceps                  ++                   ++

   Wrist                       +                     +

    Knee                     ++                  ++

    Ankle                     +                     +

    Plantar             withdrawal    extensor

Provisional diagnosis

Left Hemiplegia secondary to Right MCA territory infarct
Myocardial infarction


Treatment

RT feeds 100milk 2nd hourly
50ml water Hourly
Inj Levipil 500mg iv bd
Tab ecospirin AV 75/20mg po od
Tab lasix 40mg po bd
Syp cremaffine plus 20ml po hs


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