56 Male with Acute Infarct in Lateral Medulla

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 
A 56 years old male Who is a Cook by Occupation Presented to Casuality with C/O
Giddiness Since 2 Days
Weakness in Left LL Since 2 Days
Hiccoughs since 1 day

HISTORY OF PRESENTING ILLNESS -

Patient was apparently asymptomatic 2 days back while he was cooking in kitchen he developed Giddiness for which He went to Take Rest & After Sometime He Suddenly Developed Weakness in Lt LL.After which he has difficulty in Walking associated with Dragging of Lt LL ; Swaying to Left Side & Difficulty in Getting From Squatting Position. 
H/O Deviation of Mouth to Rt.Side
H/O Slurring of Speech
H/O Hoarseness of Voice
H/O Difficulty in Swallowing & Regurgitation of Feeds From Mouth

PAST HISTORY - 

Not a K/C/O HTN, DM ,TB, EPILEPSY, ASTHAMA ,CAD 

PERSONAL HISTORY :

DIET - MIXED,
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR , 
BLADDER MOVEMENTS - REGULAR, ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS

ON EXAMINATION -
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
ICTRUS present, 
PALLOR present, 
No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA

VITALS - 

TEMPERATURE - 97' F
PULSE RATE - 80 BPM
BLOOD PRESSURE - 160/100 MM OF HG 
RESPIRATORY RATE - 18
SPO2 - 98 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

CENTRAL NERVOUS SYSTEM : 

HMF Intact 
Gag Reflex - Absent
Eye - Ptosis of Lt.Eye ; Miosis left eye
& EOM are Normal ; No Nystagmus
Facial sensations normal
Gag reflex absent
Deviation of Mouth to right
Deviation of uvula to right.
Tongue movements are normal

Sensory system examination: Intact 

Motor : 
Tone - Normal in Both UL & Both LL 
Power - Power in Both UL & LL is 5/5 
Reflxes :   Right.         Left.
Biceps       ++               +++
Triceps      ++               +++
Supinator  ++                ++
Knee          ++                ++
Ankle         ++                ++
Plantars    Flexor          Flexor

Gait:Wide based gait with Swaying to Left

Cerebellar sings
Finger nose test normal
Heel knee test normal
No dysdiadokinesia
 
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
P/A - NO TENDERNESS & NO ORGANOMEGALY

Provisional diagnosis:?Acute Infarct left Lateral medulla


Investigations : 
ECG : 
2D ECHO :
MRI BRAIN PLAIN : 
Diagnosis : ACUTE INFARCT IN LEFT LATERAL MEDULLA

TREATMENT :
RYLES TUBE INSERTED
RT FEEDS 200ML MILK + PROTIEN POWDER + 100ML WATER ( LIQUID DIET THROUGH RT )
TAB.ECOSPIRIN 75MG RT OD
TAB.CLOPIDOGREL 75MG RT OD
TAB.ATORVAS 40MG RT HS
TAB.CINOD 10MG RT OD
TAB.BACLOFEN RT TID

DISCHARGE SUMMARY :

A 56 years old male Who is a Cook by Occupation Presented to Casuality with C/O
Giddiness Since 2 Days ;Weakness in Left LL Since 2 Days ; Hiccoughs since 1 day and after Clinical examination diagnosed with
? Acute Infarct left Lateral medulla Then Antiplatelets were started and then MRI BRAIN PLAIN was done which showed INFARCT In Left medulla and diagnosed as 
ACUTE INFARCT IN LEFT LATERAL MEDULLA WITH DENOVO HTN. Then RYLES tube was inserted and medication given through that vitals are Stable at the time of Discharge

Advise at discharge : 
RT FEEDS - LIQUID DIET THROUGH RT AND 100ML of Water after every feed
Change Ryles Tube For Every 20 Days
TAB.ECOSPIRIN 75MG RT OD
TAB.CLOPIDOGREL 75MG RT OD
TAB.ATORVAS 40MG RT HS
TAB.CINOD 10MG RT OD
TAB.BACLOFEN RT TID 
OINT.THROMBOPHOBE FOR L/A








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