A 75 year old female with burning micturition and altered sensorium (Type 2 DM since 4 yers and Hypertension since 3years)

History of present Illness: 
75 years old female presented to General medicine department with chief complaints of burning micturition since 6 months,shivering and decreased responsiveness since yesterday morning . 
Patient was apparently asymptomatic 4years back then she had a fall from stairs and got her knee injured which later got ulcerated and grafting was done, then she was diagnosed with diabetes mellitus. 3years ago she had an episode of giddiness and was diagnosed with hypertension.  3 years back she had a low back ache and was diagnosed with some kidney problem ,2 years back she had chest pain and was diagnosed with heart problem? And using medication regularly. H/o slight involuntary movements of hands.
No h/o fever , headache, neck stiffness.
No h/o head/ spine trauma
No h/o loss of consciousness, vertigo, tinnitus. 



Past history: DM - 4years
                         Hypertension- 3years 
Not a known case of tuberculosis,asthma, epilepsy, thyroid abnormalities.




Personal history: 
Diet   : mixed
Sleep : adequate
Appetite: normal
Bowel: regular 
Bladder: burning micturition since 6 months
Addictions: none



Family history: no similar complaints in family


General examination: Patient is conscious, coherent, cooperative  well oriented to time, place and person.
Patient is poorly built and nourished. 

PALLOR - present 

Icterus : absent 
Clubbing :absent 

Cyanosis:absent 
Lymphadenopathy: absent
Edema: absent

VITALS: 
BP: 160/100 mmHg
RR : 22
PR: 84
Temperature: afebrile
SpO2 : 96% in room atmosphere





Systemic examination: 

CVS: S1 S2 heard, no murmurs.

Respiratory system: BAE+ , normal vesicular breath sounds heard .

P/A :  soft ,tenderness present 

CNS: 
1. HIGHER MENTAL FUNCTIONS:

Conscious, coherent and Cooperative 

Appearance and behaviour:
Emotionally stable 
Recent, immediate ,remote memory intact 
Speech : comprehension normal, fluency normal ,No repeatitions .
Right handed individual .





2. CRANIAL NERVE EXAMINATION: 
 
*Olfactory: Normal

*Optic nerve  : visual acuity : CF 
Pupil: sluggish pupillary response to light 

*3,4,6 : normal , ocular motility is present in all directions.

*Trigeminal : normal sensory and motor 
 
* Facial nerve : forehead wrinkling present
                             Able to close eyes, able to blow                                   cheeks.

* 8th nerve : decreased hearing.

* 9 and 10 nerves: normal

*11th  nerve : SCM, trapezius : normal.

*12 th nerve : no deviation of tongue, no fasiculations.


MOTOR EXAMINATION :
 
Bulk: normal 

Tone:
                           Right                     Left

Upper limb     Normal                 Normal 
Lower limb      Normal               Normal

Power:
                           Right                       Left 
 Upper limb      3/5                          3/5
Lower limb       3/5                         3/5

REFLEXES:      Right                      Left 
 
Corneal             Absent                Absent
Conjunctival    Absent               Absent 
 
Deep reflexes  
Biceps                +                            +
Triceps              +                            +
Knee                  +                            +
Ankle                +                            +


SENSORY  FUNCTIONS 

SPINOTHALAMIC  TRACT 

Pain, temperature, pressure- intact in all limbs 

Posterior column :
 
Fine touch,vibration, proprioception  are intact

CEREBELLAR FUNCTIONS : 

Titubation: absent 
Nystagmus : absent 
Dysmetria : absent 
Dysdiadochokinesia : absent 
Intension tremor : absent 

No signs of cerebellar dysfunction.



INVESTIGATIONS :
MRI brain :

Impression: old lacunar infarcts in left lentiform nucleus. Chronic small vessel ischaemia.

LFT, RFT 


ECG : 


2D echo:


USG:


Provisinal diagnosis : cerebral stroke 


Treatment :
Inj pantop 
Inj optineuron
Inj livipil
Inj Zofer 
Inj monocef 


  









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