65M with C/O Dysphagia, headache with Blurring of vision, generalised weakness and Hoarseness of voice

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Case:

C/O DYSPHAGIA SINCE 10 DAYS

C/O HEADACHE WITH BLURRING OF VISION SINCE 4 DAYS

C/O GENERALISED WEAKNESS SINCE 4 DAYS

C/O HOARSENESS OF VOICE SINCE 10 DAYS

A 65/M , CEMENT WORKER – CHRONIC SMOKER 1 PACK BEEDIS IN 2 DAYS, CHRONIC ALCOHOLIC – 90ML WHISKY PER DAY, WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK WHEN HE HAD SUDDEN EPISODE OF VOMITING FOLLOWING DINNER AND REGULAR CONSUMPTION OF ALCOHOL, AFTER WHICH THEY NOTICED DIFFICULTY IN SWALLOWING BOTH SOLIDS AND LIQUIDS FOR WHICH HE WAS RUSHED TO HOSPITAL, TREATED FOR 1 WEEK, ( NO BRAIN IMAGING DONE, NO DOCUMENTATION OF TREATMENT), AND PRESENTED HERE AFTER 1 DAY OF DISCHARGE.

HE ALSO COMPLAINED OF EPISODIC HEADACHE WITH B/L BLURRING OF VISION AT THE TIME OF HEADACHE, SINCE 4 DAYS, A/W NAUSEA, B/L EAR FULLNESS, AND DECREASED HEARING, GIDDINESS ON CHANGING POSITION, HAD LOCAL EAR TRAUMA TO LEFT EAR, WHEN WIFE TRIED TO CLEAN IT WITH TOOTH PICK.

H/O HTN SINCE 5-6 MONTHS, USED OVER THE COUNTER TREATMENT FOR 1-2 MONTHS AT THE TIME OF HEADACHE.

PERSONAL HISTORY :

MARRIED

OCCUPATION: CEMENT WORKER

APPETITE: LOST

DIET: MIXED

B&B: REGULAR

ADDICTIONS: CHRONIC SMOKER 1 PACK BEEDIS IN 2 DAYS, CHRONIC ALCOHOLIC – 90ML WHISKY PER DAY.

NO SIGNIFICANT FAMILY HISTORY

ON GENERAL PHYSICALN EXAMINATION:

PT IS C/C/C,, NO SIGNS OF PALLOR , ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA.

VITALS:

AFEBRILE

PR: 102 BM

RR: 16 CPM

BP: 130/90 MM HG

SPO2: 98% AT RA

CVS: S1S2+, NO MURMERS

RS: DECREASED BREATH SOUNDS IN B/L ISA, SSA

P/A: SOFT, NON TENDER

CNS: RT LT

TONE: LL N N

             UL N N

POWER:

             UL 4/5 4/5

             LL 3/5 3/5

REFLEXS:

            B 2+ 2+

            T 2+ 2+

            S 2+ 2+

            K 2+ 2+

            P M M

            A 1+ 1+

INVESTIGATION:

2D ECHO: EF - 58%, TRIVIAL TR+/MR+, NO MR, NO RWMA , NO AS/ MS, SCLEROTIC AV,  GOOD LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION +, NO PAH/PE

MRI BRAIN: E/O ACUTE INFARCT NOTED IN INFERIOR LEFT CEREBELLAR HEMISPHERE AND LEFT LATERAL PORTION OF MEDULLA  S/O POSTERIOR CIRCULATION STROKE - MOST LIKELY LEFT PICA TERRITORY INFARCT.

TREATMENT GIVEN:

T. ASPIRIN: 75MG PO OD

T. CLOPIDOGREL 75 MG PO OD

T. ATORVAS 20 MG PO H/S

NEB WITH DUOLIN – 8TH HRLY

VITALS MONITORING

Patient Left Against Medical Advice On 01/10/21.