A 65 year old male came with chief complaints of chronic vomitings since 2 months.
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A 65 year old male farmer by occupation resident of valigonda came to the opd with chief complaints of chronic vomitings since 2months.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 2years back then he complained of giddiness and pain in the right knee since then. He went to the local rmp and was diagnosed with hypertension and was prescribed with amlodipine since then. But pain in the knee did not decrease.
Later since 2months patient complains of vomitings. Which is non projectile, not foul smelling, non blood stained and food and water as it’s content and scanty in quantity, nearly 1-2 episodes every day after the intake of food.
Patient lost nearly 10kgs of weight in last 3months.
Patient is unable to walk since when he had complained of vomitings.
There is no history of fever, cough, burning micturition, constipation, headache.
Daily routine
Includes , he wakes up in the morning gets freshen up and takes tea and tiffin and leaves to work , comes home for lunch or sometimes takes the lunch to the farm that varies, does all his work on his own and takes care of the oxes in his home, comes back home has his dinner and sleeps.
Since 2 years he complains of pain in the knee but still was able to do his regular activities on his own and visited the local rmp for the pain used some medication for 10-15 days. Pain increased on work and relieved on rest. Then the patient had vomitings since 2months and visited various hospitals for the same.
PAST HISTORY
Patient is a known case of hypertension since 2years and was under medication since then with amlodipine.
He is not a known case of DM, CAD, CVA, epilepsy, TB, asthma.
There is surgical history.
FAMILY HISTORY
Not significant.
TREATMENT HISTORY OR DRUG HISTORY
Patient doesn’t have allergies to any kind of food particles or drugs.
PERSONAL HISTORY
DIET :- mixed
APPETITE :-decreased
SLEEP :- adequate
B&B :- decreased since 3 days.
ADDICTIONS :-no
GENERAL EXAMINATION
Patient is conscious coherent and cooperative, oriented to place and person but not time.
There are no signs of pallor , icterus, cyanosis, clubbing, lymphadenopathy, koilonychia and pedal edema.
Vitals
Temperature :- afebrile.
Pulse :-88bpm.
B.P :- 110/80 mm of hg.
R.R :- 18cpm.
SYSTEMIC EXAMINATION
CVS:- S1, S2 heard. No murmers heard.
RS:- bilateral air entry is present , normal vesicular breath sounds are heard.
P/A :- soft and non tender.
CNS:- sensory
Spinothalamic:-
Crude touch , pain, temperature are normal on both upper and lower limb.
Posterior column:-
Fine touch is normal on both the sides.
Romberg sign is positive.
Cortical:-
Tactile localisation is normal on both the sides.
Meningeal signs :- not seen.
Speech is normal.
MMSE score:-25/30.
Cranial nerves:-
Cr. N 1,7,8,9,10,11,12 :- are normal on both the sides.
Cr. N 2:- field of vision decreased on both the sides.
Colour vision is normal on both the sides.
Cr. N 3,4,6:- extra ocular movements decreased in the left eye and normal in the right eye.
Pupil size:- nsrl on both sides.
Direct indirect reflexes are normal on both the sides.
Pyrosis is absent.
Nystagmus is elicited in the left eye.
Cr. N 5:- sensory and motor reflexes are normal.jaw jerk is absent.
Motor system.
Bulk is normal on both the sides.
Tone is normal on both the sides.
Power is 5/5 on both the sides in upper and lower limbs.
Reflexes. R L
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Plantar flexors extensors
Cerebellar signs.
Gait- swaying towards left.
Involuntary movements: (-)
Nystagmus(+) left.
Pendular knee jerk (+)
Titubation (-)
Dysarthria, hypotonia :- (-)
Coordination movements
Finger nose test (+)
Dysdiadokokinesia (+)
Heel knee test (+) on left and (-) on right.
INVESTIGATIONS
- Lesion is causing compression & displacement of 4th ventricle to contralateral side with resultant mild dilatation of lateral and 3rd ventricle - Suggestive of acute hydrocephalus.
-Periventricular hyperintensity suggestive of transependymal seepage of CSF.
PROVISIONAL DIAGNOSIS
Chronic vomitings is secondary to cerebellar lesion that is compressing 4th ventricle?
- acute hydrocephalus that is secondary to mets? or primary brain malignancy.
MANAGEMENT
17/12/22
INJ ZOFER 4MG IV TID
INJ PAN 80MG IN 50ML NS CONT IV INFUSION
IVF AT 75ML/HR
ORS 1 PACKET IN GLASS OF WATER IN SIPS
GRBS 4TH HRLY
18/12/22
INJ OPTINEURON 1AMP +100 ML NS IV OD
INJ ZOFER 4MG IV TID
TAB PAN D 40/30 PO/BD
IVF AT 75ML/HR
ORS 1 PACKET IN GLASS OF WATER IN SIPS
PROCTOLYTIC ENEMA
GRBS 4TH HRLY
19/12/22
INJ OPTINEURON 1AMP +100 ML NS IV OD
INJ ZOFER 4MG IV TID
TAB PAN D 40/30 PO/BD
IVF AT 75ML/HR
ORS 1 PACKET IN GLASS OF WATER IN SIPS
TAB AMLONG 5MG PO OD
GRBS, BP 4TH HRLY
20/12/22
INJ OPTINEURON 1AMP +100 ML NS IV OD
INJ ZOFER 4MG IV TID
TAB PAN D 40/30 PO/BD
IVF AT 30ML/HR
TAB SHELCAL CT PO OD
TAB JOINTACE PO OD
D2 INJ LEVERA 500MG IV BD
D2 INJ DEXA 8MG IV TID
GRBS, BP 4TH HRLY
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