CASE 5

A 55 year old patient of mechanic in occupation  and resident of nalgonda came to hospital with compliants of slurring of speech, difficulty in swallowing and drooling of saliva and cough since 10 days.
CHEIF COMPLAINTS:
slurring of speech since 8 hrs
Unable to swallow since 8 hrs 
Drooling of saliva - 8 hrs
Generalized weakness-10 hrs
HOPI:
Patient was asymptomatic 8 hrs ago before visiting the hospital then he suddenly developed slurring of speech,drooling of saliva and difficulty in swallowing and generalized weakness and constipation 
NO H/O loss of involuntary movements
NO H/O visual disturbances
NO H/O.  SOB, FEVER, AND NUMBNESS OR TINGLING OR WEAKNESS IN UPPER AND LOWER LIMBS
NO H/O VOMITING
PAST HISTORY:
c/o cough since 10 days which is insideous in onset, gradually progressive and is productive in nature But was not able to spit it out
History of CVA 3 Years ago and acute CVA which occurred recently
History of HTN 3 YRS ago
History of inferior wall CAD and Grade -1 hepatic encephalopathy.
NO H/O
TB
DM 
ASTHMA
EPILEPSY
BLOOD TRANSFUSIONS
THYROID DISORDERS
 PERSONAL HISTORY:
 Appitite is normal
 Mixed diet
 No allergies
Bowel movements are irregular has constipation 
Addictions
Alcohol intake of 6-9 units of whiskey thrice a day since 27 years
Smoking has a habit of smoking 2-3 cigarette packets since 27 years
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient is conscious, coherant and not cooperative
NO PALLOR
ICTERUS
LYMPHADENOPATHY
CYNOSIS
CLUBBING
PEDAL EDEMA
VITALS:
Temp- febrile

Pulse-84 BPM
B.P- 110/70 mm/Hg
Spo2 - 98%
CNS EXAMINATION:
Speech is slurred
Patient is conscious
MOTOR REFLEXS:
KNEE JERK 
RT -.     Present
LT-.        Not present      
ANKLE REFLEX:
RT-.  Present
LT.-.  Not present
BABISKIES SIGH :
RT-  present
LT-  Not present
BICEPS- 
RT- Present
LT- Present
TRICEPS
RT - Present
LT- Not present       
SENSORY EXAMINATION:
Patient was not able to Ellicit
CRANIAL NERVES EXAMINATION:
INTACT
CVS EXAMINATION:
S1 and S2 sounds heared
No cardiac murmurs 
Investigations:
ECG:
RESPIRATORY EXAMINATION:
Trachea -  Central line in position
Wheeze is present
Breath sounds are vesicular
No signs of dypnoea
ABDOMINAL EXAMINATION:
Abdomen is distended
No tenderness
No palpable mass
No bed sores
No fluid thrill or shifting dullness
No hernial orifaces
PROVISIONAL DIAGNOSIS:
Left hemiparesis with Grade -1 hepatic encephalopathy.
Treatment:


                 
              
  
                                       
                                      











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