65 year old with weakness and history of falls with loss of consciousness since 8 months







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65 year old farmer by occupation, stopped working since 8 months because of weakness, has history of frequent falls since 8 months,associated with loss of consciousness for 10-15 minutes,post ictal confusion,initially had history of fall only during work/stress.Now since 4 days even at rest patient developed involuntary movements with frothing from mouth ,stiffness-lasting for 10-15 minutes,associated with post ictal confusion for 30 minutes, 

no bowel and bladder incontinence. seizure episodes of 5-10 episodes/day, slurring of speech intermittently. 

No history of dysphagia

Complaints of fever since 4 days,high grade associated with chills and rigors, continuous type, 

not associated with nausea, vomitings ,

loose stools,cold,cough



Difficulty in lifting arms above shoulders since 8 months 

Difficulty in getting up from sitting position 

Heaviness of left upper limb

No slippage of footwear

Able to mix food,able to comb,button and unbutton shirt

Past history:

K/c/o HTN since 1 year, on irregular medication.

3 years back history of RTA ,nail was put in left forearm-implant insitu

No history of DM, aasthma,epilepsy,CAD.

Personal history 

Diet: mixed

Appetite:normal

Bowel and bladder: regular

Micturition:normal

 Chronic smoker since 50 years( 1 packet of beedi/day)

Alcoholic since 50 years-toddy, sara(home made liquor)


General examination:patient is conscious coherent cooperative.

Well built and moderately nourished.

no pallor, icterus,cyanosis, edema , lymphadenopathy, clubbing.

Vitals:

Bp- 190/100 mm hg

Pulse: 60/min

temperature:98.4F

Respiratory rate: 17/min

Spo2:99% at RA



Systemic examination: 


CVS: S1 S2 heard, no murmurs

RS:  chest is barrel shaped, B/L air entry present

Ap diameter-26cms

Transverse diameter-26cms



       

Per abdomen: shape- scaphoid

No tenderness, no palpable masses, liver and spleen not palpable 


CNS:

MMSE EXAMINATION:

Orientation:5/5

Registration:3/3

Attention and calculation:2/5

Recall:3/3

Language:2/2

                 1/1

                 3/3

Total:        19/30

           



Intellectual functions:

patient oriented to time place person

Conscious+

Memory+

Orientation +

normal speech

Sleep normal

Gait: normal





                       Motor system

                        Right.               Left

Bulk.  

UL-       

ForeArm         23 cms        23cms(Hand-thenar and                       hypothenar wasting)



Arm                23cms.      23 cms

LL-      

Above knee      35 cms     

Below knee.     28.5cms.       26cms


Tone    UL-  N              Increased

             LL-   N              Increased

Power-

UL- proximal 5/5.             5/5 

        Distal.    5/5.              5/5

LL- proximal-5/5              5/5

       Distal.      5/5.             5/5

Hand grip-     80%.          20%

Reflexes  Biceps Triceps supinator knee   ankle

Right.      +3.        +2.       +3.             +2.    -

Left.         +3.        +2.       +3.             +3    +2


Superficial reflexes 

                          Right             Left              

Corneal               +                 +

Conjunctival       +                 +

Abdominal         +                  +       

Plantars-        Flexion.        Flexion


Sensory:                  Right.              Left

Lateral ST tract:       

Temp:                        +                   +

Pain:                          +                   +


Anterior ST tract:

Pressure:                  +                    +

Crude touch:            +                    +


Dorsal column:

Joint position.         +                    +

Vibration.  UL.       N.                  N

                  LL  absent in knee absent at knee

                         + at ankle.      + at ankle


Fine touch.           N.                    N


Cortical 

    stereognosis.    N.                    N


Cerebellar

      Dysdiadokinesia.          -

      Rhombergs.                  -

     Tandem walking.           -

Finger nose coordination    +

Finger finger coordination.  +


No signs of neck stiffness 

Kernig’s sign: negative 

Brudzinski’s- negative 


Cranial nerves : normal

      

 MRI:

Impression: chronic lacunar infarcts in bilateral thalami, left lentiform nucleus,left corona radiata and right centrum semi ovale.

Age related mild cerebral atrophic changes with chronic ischemic changes

                



Investigations 


Xray



Ecg:

        





2d echo:

               

Hemogram:





Liver function tests:





Renal function tests




CUE:


Thyroid function tests


Lipid profile 



Erythrocyte sedimentation rate:


C reactive protein:

Random blood sugar



Fasting blood sugar:




Provisional diagnosis:

Epilepsy 

old CVA, 

Alcoholic myopathy 

hypertension, alcoholic, smoker 


Treatment:

Day 1: 

Inj.lorazepam.2cc/IV/SOS if repeat seizure activity 

Inj.Thiamine 1 amp in 100ml NS/IV/BD

W/F  repeat seizures

Inj.PAN 40mg/IV/OD

Inj. Sodium valproate 800mg in 100ml NS/IV/stat followed by tab.encorate 200mg/PO/BD

Tab.Ecospirin AV 75/10mg PO/OD

Temp.charting 4th hourly


Day 2:

Tab.encorate 200mg PO BD

Tab.Lorazepam 2cc IV SOS if repeat seizures

Inj.Thiamine 1 amp in 100 ml NS IV BD

W/F repeat seizure

Inj. Pan 40 mg OD

Tab.Ecospirin AV 75/10mg PO/OD

Temperature, BP charting 4 hourly

Tab.Amlong 10 mg PO OD

Inj.Optinueron 1 amp in100ml NS IV OD

Tab.Bacfen-XL 20 mg HS

Tab.Lorazepam 2mg  PO BD


Same treatment continued on day 3,4 and 5


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