45 Male with dysphagia to liquids
45 year old male patient resident of miryalguda having 3 children, married at the age of 20 years, daily wage labourer( weight lifting).
Patient is chronic alcholic consumes 180ml- 1 full bottle of whiskey since 20 years, and chronic smoker- beedis 20/ day
4 years ago patient had history of trauma to right nail and in view of delayed healing they got tests done and was diagnosed with Diabetes Mellitus and was started on OHA's. But sugars were not controlled and were high in previous reports.
Patient's wife c/o patient taking large quantities of food and is always hungry (1/4-1/2 kgs rice intake daily) ? Polyphagia
On further asking he gives even history of polydypsia and polyuria. Gets up approximately 5-6 times in the night for micturition.
In v/o uncontrolled sugars patient was shifted to H.Mixtared 24U-16U. But patient takes it irregularly and takes alcohol in between
Attender even gives history of weight loss but no h/o fever, cough
Since 8 months patient c/o increased frequency of stools and loose watery stools 6-8 times /day, small quantities, Not associated with pain abdomen. Patient' s wife even c/ o rice grains seen in stolls and it was not digested . No mucoid stools , non bloody. No vomitings.
No decreased urine output back then. Since 6 months c/o incontinence of stools and urine . Patient attenders gives history of passage of urine in between before reaching washroom ( overflow incontinence), bed wetting +
Now since 1 week decreased stool frequency . Since 10 days patient c/o generalised weakness and unable to get up from bed. Walks or goes to washroom with support of attenders.
Also c/o difficulty in swallowing to liquids since 10 days and coughing on taking liquids. Able to take solid food. C/o slurring of speech since 10 days.
No h/o weakness of limbs, deviation of mouth, loss of consciousness, seizures. No h/o headache.
C/o decreased urine output since 1 day. No slippage of footwear
C/o tingling in bilateral lowerlimbs. Patient now has delayed response to commands and slurring of speech. Able to understand.
O/e : pt conscious and confused.
Bp- 80/60 mmhg
Pr - 100bpm
Cvs - s1s2rs - bae present .clear.
Grbs - 303 mg/dl
Afebrile .
Spo2- 96% on ra.
CNS EXAMINATION :
Pt conscious ,but confused and lethargic .
Delayed response to commands .
Pupils - b/l normal size reacting to light .
GCS -E4V4M6
MOTOR SYSTEM :
BULK - decreased on both sides upper and lower limbs.
Measurement -
TONE - UL - Normal -b/l
LL - Normal-b/l
REFLEXES : B. T. S. K. A. P
R. -. -. -. -. -. WITHDRAWAL
L. -. -. -. -. +1. -. Withdrawal
Power - R. L
UL. 3+/5. 3+/5
LL. 3+/5. 3+/5
Pt not following commands .
Sensory examination - pt not following commands.
CRANIAL NERVES :
II - Pupils - NSRL
CF -3 m
III,IV,VI - EOM INTACT
V - Corneal and conjunctival relfex intact
VII - ABLE to close eyes completely. No lagopthalmus
No deviation of mouth.
IX - Gag reflex absent
X -Deviation of uvula to right side.
SLURRED SPEECH present .Nasal twang present.
XII - NO Tongue deviation, fasciculations .
EXAMINATION VIDEO LINKS :
https://youtube.com/shorts/10sI-qdUZt8?feature=share
DIAGNOSIS -
1) Dysphagia to liquids (?oral candidiasis) along with
Slurring of speech - ?Bulbar palsy - secondary to ? Acute CVA / ? GBS .
2) Bowel amd bladder incontinence secondary to ??diabetic autonomic neuropathy .(? over flow incontinence)
3) Chronic diarrhoea /osmotic diarrhoea secondary to ? chronic pancreatitis /uncontrolled sugars.
4) ??Delirium secondary to alcohol withdrawal
5) Hypokalemia under evaluation.(3.2- s. potassium)
6) Diabetic neuropathy
7) Uncontrolled sugars - Type 3C diabetes
8) Chronic alcoholic and smoker .
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