65 year old male

Chief complaints :
 65 year old male with chief complaints with unable to walk since 3 months , muscle stiffness since 20 days , decreased appetite since 15 days . Unresponsiveness since 3 days. 
History of presenting illnesses: Patient is apparently asymptomatic 1 year back then developed unbalanced gait,insidious in onset and visited a hospital ,6 months ago and was said to be having a neurological disease (no documents available) and have been using medication since then(not known)and was having generalised weakness on and off since 6 months and due to fear of falling and as he is feeling pricking sensation over the sole,and due to decreased power in his limbs and generalised weakness he completely stopped walking  and was bed ridden since 2 months(he didn’t tried walking even with support)visited a hospital again 1 month back,MRi brain was done,showing hydrocephalus and early parkinsons changes,and advised for surgery (?Ventriculoperitoneal shunting,not done)and during hospital stay diaper was placed for 3 days and after discharged home his wife noticed macerated skin and thus avoided wearing a diaper since then,2 mnths back he used to eat himself(by mixing the food himself,and buttoning his shirt)and since ,2 months  his wife is making him eat food,and 1 month ago he once passed urine on his bed,soon after which, they placed a foleys (and changed after each week)and his wife used to turn him to side and made him pass his stools(to avoid maceration of skin due to diaper),and since 15 days he had flexion contracture of his both limbs ,soon after which his wife massaged with oil and thus contracture relieved little bit,but he was Unable to move his lowerlimbs(moving his upperlimbs against gravity),and he is having decreased Apetite since 10 days and is not eating food so they kept him on Iv fluids (1 bottle in a day)since 10 days,and he was not responding to commands since 3 days and fever which is of high grade not associated with chills and rigors since 2 days,releived on taking medication,and came here for further management.


Past history: He is known case of hypertensive since 4 years , 
known case of Diabetic since 3and half years on glimipiride 2 mg + metformin 500 mg
History of trauma - by fall from auto - fractured his right  leg
No history of Tuberculosis, Asthma , Epilepsy 
 No history of , blood transfusion and any surgeries done. 
History of fever one month back , relieved on medications
 Personnel history: married since 35 years Gold smith by occupation Diet - mixed , non vegetarian 
 Bowel and bladder movements - Regular. 
No allergies 
 Addiction - Alcoholic since 30 years, 
Non smoker.
250 ml per day
 Family History: Not significant

   General examination :
 Patient is in concious but drowsy and unresponsive, not oriented to time, person and place Malnourished and poorly built.
 Blood pressure - 110/ 80 mmhg.
 pulse rate - 96 bpm , normal rhythm and volume Respiratory rate 22 cycles per min. 
Temperature - afebrile 
Pallor
 No signs of   icterus , cyanosis , clubbing and lymphadenopathy and edema.
 Systemic examination:
 R respiratory system: Bilateral air entry present,normal vesicular breath sound heard,
 trachea is central on palpation. 

 Cardio vascular system : S1 , S2 heard and no murmurs detected
   Per Abdominal examination : Soft and non tender. 

 Central Nervous system examination: 
 Higher mental functioning: Patient is conciouss ,non coherent and not oriented to time place and person .
 Right handed.
 Language : Speech - Aphasic - unable to speak. 
Unable to read and write. 
 
Sensory system:cannot be elicited. 
Motor system : Muscle wasting is present , no cramps , no twitching and no involuntary movements 
 Cranial nerve examination: 
1.Olfactory nerve
2.Optic nerve
3.Occulomotor nerve: Normal
4.Trocheal nerve : Normal
5.Trigeminal nerve 
Gag reflex present
6. Abducens nerve : normal
8.vestibulocochlear nerve
9. Glossopharyngeal nerve and 10. Vagus nerve- difficulty in speech 
11.spinal accesory nerve.
12. Hypoglossal nerve
 Tone: Both upper limbs and lower limbs were flexed with increased tone in both flexors and extensors of upper and lower limbs .
Power is 3/5 in upper limbs 
Power in lower limbs could not be elicited
 Superficial reflexes : Coneal reflex , conjunctival reflex ,abdominal and plantar reflex present . 
 Deep tendon reflxes : 
 Biceps reflex : 2+ 
Triceps refkex 2+
 Supinator 2+ 
 knee jerk reflex could not be elicited. 
JAW JERK reflex- present. 
Babinskis reflex : withdrawal of foot 
 No signs of meningeal irritation. 
Gait could not be assessed . 
 Glassgow coma scale : 
 Eye opening - To speech - 4
 verbal response - no response - 1 
Motor response - localising pain

Provisional diagnosis : Altered sensorium due to hypovolemic hyponatremia 
Parkinson's disease

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