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CASE OF ACUTE INFERIOR CEREBELLAR INFRACT WITH HYPERTENSION
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CASE:-
A 57 year old male , an autodriver, from gundlasrinagaram a autodriver by occupation came with complaints of
CHIEF COMPLAINTS
- Bilateral Lower limb pain
- Giddiness since 4 days
- Excessive sweating since 4days
- Swaying towards right since 4 days.
- Hypertensive urgency (170/100)
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 4 days when he developed
Pain and swelling of bilateral lateral malleolus,for which he visited he visited local RMP,for which he received an injection?
Following this he developed excessive sweating and giddiness with swaying towards right
Difficulty to walk for which he went to a local hospital and was advised to get a CT done,and medications were given,and was referred here for further management
He arrived here as hypertensive urgency with a blood pressure of 170/100 and Giddines and diplopia
He is diagnosed as hypertensive 2 years ago and is on medication but only used for 3 months
No history of headache,nausea,vomiting, blurred vision , or involuntary moments.
PAST HISTORY
No similar complaints in the past
Not a known case of Diabetes,Tb,Asthama,Epilepsy,Cvd,Chemotherapy
PERSONAL HISTORY
Mixed diet
Apetite Normal
Sleep adequate
Bowel and Bladder moments regular.
Addictions: Chronic alcoholic since 20 years, stopped 2 years back
Chronic beedi smoker since 22 years.
FAMILY HISTORY
No significant family history
General examination
Patient is conscious coherent cooperative oriented to time place person
VITALS:
- Afebrile
- Bp:160/80mmHg in left arm in sitting position
- PR:86bpm
- RR:16Cpm
- Spo2 : 98%
- NO PALLOR
- NO ICTERUS
- NO CYANOSIS
- NO CLUBBING
- NO KOILONYCHIA
- NO LYMPHADEONAPTHY
SYSTEMIC EXAMINATION
- Apex beat felt at 5th intercostal space
- Heart sounds normal
- No thrills and murmurs
- Chest symmetrical
- Normal vesicular breath sounds
- No crepts,rhonchi,rales
- Soft and non tender
- No organomegaly
- No visible scars and sinuses
HIGHER MENTAL FUNCTIONS:
The patient is conscious coherent and cooperativer And oriented to time place and person
Cranial nerve:No abnormalities detected
MOTOR SYSTEM:
No muscle wasting is observed.
Tone of all muscle normal
Power of all muscle 5/5
Broad based gait
No involuntary movements or tremors are seen.
SENSORY SYSTEM:
All sensation retained
No abnormal sensations are present
Cerebellar function
Trunkal ataxia/gait ataxia swaying towards right
No dysarthria,tremors,hypotonia
Coordination tests:
Finger nose test: normal
No overshooting.
Finger to finger testing:no incordination.
Diadokokinesia: normal with right hand.
Heel knee test: no incordination
Rhombergs test: swaying towards right with eyes open
Autonomic nervous system:
Increased sweating +
No postural hypotension
Meningeal signs:
No neck pain
No spinal and cranial abnormalities
No carotid bruit
Provisional diagnosis
Acute inferior cerebellar infract
Investigation
Treatment
Day 1
- TAB ECOSPORIN 75MG/PO/OD
- TAB CLOPTTAB 150 MG/PO/OD
- TAB ATORUAS 80 MG/PO/OD
DAY 2
- TAB ECOSPORIN 75MG/PO/OD
- TAB CLOPTTAB 150 MG/PO/OD
- TAB ATORUAS 80 MG/PO/OD
- TAB SPINFREE PO/BD
- BP MONITORING
DAY 3
- TAB ECOSPORIN 75MG/PO/OD
- TAB CLOPTTAB 150 MG/PO/OD
- TAB ATORUAS 80 MG/PO/OD
- TAB SPINFREE PO/BD
- BP MONITORING
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