A 40 year male with difficulty in swallowing and deviation of mouth.

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Here is a case i have seen:

A 40 year male,security guard by occupation came to the casualty on 15/8/20 with the complaints of difficulty in swallowing since 3 days,Deviation of angle of the mouth to left and numbness of left half of the body since 2 days,Giddiness intermittently on walking since 1 day

On 13/8/20, there was a sudden difficulty in swallowing for about one hour in the morning and again difficulty in swallowing occured in the evening and it got continued from then. It was non progressive, associated with drooling of saliva,nasal regurgitation on drinking water ,not associated with pain and difficulty in mastication on right side,not associated with difficulty in closure of eye, no foreign body sensation in the throat.

Deviation of angle of mouth to left and numbness of left half of the body since 2days:
On 14/8/20, at around 11am in the morning while he was eating a cake, he was unable to swallow and decreased mastication on right. and then he developed deviation of the mouth to the left and also he developed numbness in the left side of body on the same day.Not associated with loss of consciousness,seizures,hearing difficulty,shortness of breadth, speech not impaired.

He also complained of giddiness intermittently on walking since last evening.  no positional variation.

7 years back, after the alcohol binge on one night,the day following it he developed profuse sweating ,giddiness and he went to his grandfather's clinic and he was diagnosed to be denovo diabetic,and started on OHS.he used for 6 months and stopped after a checkup which came out to be normal.

He used antihypertensive medication for 3 months as he was told his systolic bp was 200 by an RMP.(on asking patient doesn't have any prescription or tablets with him to know the specific medication).

He started intake of alcohol (beer)from 14 years of his age twice monthly and daily intake of alcohol(beer) from 18 years of his age of about 360ml.

Family history:
His father and grand father had CVA.
His mother is diabetic and died because of MI 

General physical examination:

 Patient is conscious,coherent and cooperative.well built and nourished

Temperature : afebrile
Pulse               : 77bpm
Respiratory rate: 28 cycles/min
Blood pressure  : 180/90 mm of hg
Spo2                     : 97% at room air
Grbs                      : 172 mg/dl.

No pallor, icterus, clubbing, cyanosis, koilonychia,lymphadenopathy and pedal edema

SYSTEMIC EXAMINATION:

CNS:

Higher mental functions :
patient is oriented to time,place ,person
Speech is normal in pitch and tone
Memory: recent and remote memory intact

Cranial nerves:
CN s1,2,3,4 are intact on examination
CN 5 : jaw jerk present,mastication decreased on right side,sensations decreased on right side of face
CN 6 : intact
CN  7 : deviation of angle of mouth to left         frowning absent on right.unable to close tightly on the right.No blowing on right,loss of naso labial folds.

DEVIATION OF ANGLE OF MOUTH TO LEFT

Sensory:

CN 8 : Rinnes : BC>AC, webers : central.

CNs 9 and 10 : dysphagia present,gag reflex present soft palate uvula deviated to left

CN 11 : intact

CN 12  : tongue tone normal,no wasting,no fibrillations and base of tongue deviated to right.

Motor:

Tone  :   UL           LL

Rt            N             N

Lt             N             N

Bulk  :              

Rt              N             N

Lt               N             N

Power :   

Rt                N            N

Lt                 N            N

Hand grip:   100%     100%     

        

Reflexes :   superficial reflexes-

Cornel,conjunctival and abdominal reflexes: normal

Deep reflexes:  UL: biceps,triceps,supinator- normal

LL : knee,ankle and plantar reflexes are normal

Romberg's negative

Sensory :           Rt             Lt

 Fine touch        N               DECREASED

Crude touch      N               DECREASED

Pain/temp         N               DECREASED (TO COOL)decreased to 40% on left side of face and body.

Vibration           N                  N

Joint position    N                 N

Proprioception   N                N

Cerebellum:     No finger nose incoordination

                          No dysdiadokinesia

                          Kneel heel test normal

Gait  :    Normal

No signs of meningeal irritation

Gcs  :  15/15

CVS   :  S1 S2 heard, no murmurs.

RS      :BAE present, normal vesicular breath sounds were heard, no added sounds.Traches central in position.

ABDOMEN: obese,no tenderness and no palpable mass present.Hernial orifices are free.Liver and spleen are not palpable.Bowel sounds are present. 

INVESTIGATIONS :     DAY 1:

MRI brain (plain) : Acute infarct on medial medulla oblongata.

Plbs- 178 mg/dl.

                      DAY 2:

On examination, Crepts in right lung.

   INVESTIGATIONS ON DAY 2:

Chest xray:

MRI Brain

Colour doppler 2d echo: IVC dilated (1.7cms),not collapsing

Good LV systolic function present.

No diastolic dysfunction.

FUNDOSCOPY: Normal fundus study.

On examination : Rt eye mild ptosis,left eye lower lid retraction. Extraocular muscles functions in both eyes -good

2D ECHO link:

https://drive.google.com/file/d/1-EwMHqz-IZq6b-2GxcrWtxN457febiYd/view?usp=drivesdk

An episode of focal seizure with secondary generalisation at 1:10 pm. Drooling of saliva present ,uprolling of eyes,No tongue bite, No post ictal confusion. he was given IV lorazepam 4cc stat 

Inj Levipril 1gm Iv loading dose.

Inj levipril 500mg IV BD 

While patient is on routine examination,he went into supra ventricular tachycardia at around 2:30pm with heart rate of 190beats/min ,irregular and he was apparently asymptomatic at the time of ventricular tachycardia.no giddiness,no palpitations ,sweating and shortness of breadth.

Vagal manoveur done for 15 minutes.injection adenosine 6mg iv stat followed by inj adenosine 12 mg iv  given and on no response,Inj adenosine 12mg iv given again.On no response,inj diltiazem 20mg iv stat given.

DIAGNOSIS :  lateral medullary syndrome.

TREATMENT:

Head end elevation 

 Ryles tube insertion.

 BP monitoring hourly (maintain BP > 160mm of Hg)
GRBS 6th hourly 

  Inj.optineuron 1 ampoule in 100ml NS IV /BD
Inj levipil 500mg Iv Bd
Tab Ecospirin 150mg OD/RT
Tab Atorvas    40mg H/S RT

I/O charting
BP ,spo2,PR hourly monitoring
Tab clopidogrel 75 mg OD/RT
RT feeds : 100 ml of water hourly
                     200 ml of milk 2nd hourly
Tab Metformin 500mg OD

Tab Telma 40mg OD