45 year old male came with the complaints of

45YRS OLD MALE
45 year old male patient resident of miryalguda having 3 children, married at the age of 20 years, daily wage labourer
( weight lifting).

Patient came with the complaints of weakness since 10 Days
Inability to speak since 10 days
Inability to swallow liquids since 10 days
Burning micturition for 2 days

Patient is chronic alcholic consumes 180ml- 1 full bottle of whiskey since 20 years, and chronic smoker- beedis 20/ day.

4 years ago patient had history of trauma to right nail and in view of delayed healing they got tests done and was diagnosed with Diabetes Mellitus and was started on OHA's. 
But sugars were not controlled and were high in previous reports.
Patient's wife c/o patient taking large quantities of food and is always hungry (1/4-1/2 kgs rice intake daily) ? Polyphagia
On further asking he gives even history of polydypsia and polyuria. Gets up approximately 5-6 times in the night for micturition.
In v/o uncontrolled sugars patient was shifted to H.Mixtard 24U-16U. But patient takes it irregularly and takes alcohol in between 
Attender even gives history of weight loss but no h/o fever, cough
Since 8 months patient c/o increased frequency of stools and loose watery stools 6-8 times /day, small quantities, Not associated with pain abdomen. 
Patient' s wife even c/ o rice grains seen in stools and it was not digested . No mucoid stools , non bloody. No vomitings.
No decreased urine output back then. Since 6 months c/o incontinence of stools and urine . Patient attenders gives history of passage of urine in between before reaching washroom ( overflow incontinence), bed wetting + 

Now since 1 week decreased stool frequency . Since 10 days patient c/o generalised weakness and unable to get up from bed. Walks or goes to washroom with support of attenders.
Also c/o difficulty in swallowing to liquids since 10 days and coughing on taking liquids. Able to take solid food. C/o slurring of speech since 10 days.
No h/o weakness of limbs, deviation of mouth, loss of consciousness, seizures. No h/o headache.
C/o decreased urine output since 1 day. No slippage of footwear
C/o tingling in bilateral lowerlimbs. Patient now has delayed response to commands and slurring of speech. Able to understand.
O/e : pt conscious and confused.
Lean built 
Temp: afebrile
BP- 80/60 mmhg
PR - 100bpm
RR- 15 cpm

Cvs - s1s2 heard
Respiratory system  bae present .clear.
Grbs - 303 mg/dl
Spo2- 96% 

CNS EXAMINATION :
Pt conscious ,but confused and lethargic .
Delayed response to commands .
Pupils - b/l normal size reacting to light .
GCS -E4V4M6

CRANIAL NERVES :
II - Pupils - Normal size reactive to light
III,IV,VI - EOM INTACT
V - Corneal and conjunctival relfex intact
VII - ABLE to close eyes completely. No lagopthalmus
No deviation of mouth.

IX - Gag reflex absent
X -Deviation of uvula to right side.
SLURRED SPEECH present , drooling of saliva while talking.
 XII - NO Tongue deviation, fasciculations .

MOTOR SYSTEM : 
BULK - decreased on both sides upper and lower limbs.
Measurement -
TONE - UL - Normal -b/l
              LL - Normal-b/l
Power - Right  Left
UL.           3+       3+
LL.            3+      3+

REFLEXES : 
                      Right.          Left
Biceps           2+.               2+
Triceps.          2+.              2+
Supinator.      2+.               2+
Knee               1+.               2+
Ankle.             1+.               1+
Plantar.          Babinski not seen




Sensory examination - pt not following commands 
Gait -










DIAGNOSIS - 
1) Dysphagia to liquids (?oral candidiasis) along with
Slurring of speech - ?Bulbar palsy - secondary to ? Acute CVA / ? GBS .
2) Bowel and bladder incontinence secondary to ??diabetic autonomic neuropathy .(? over flow incontinence)
3) Chronic diarrhoea /osmotic diarrhoea secondary to ? chronic pancreatitis /uncontrolled sugars.
4) ??Delirium secondary to alcohol withdrawal
5) Hypokalemia under evaluation.(3.2- s. potassium)
6) Diabetic neuropathy 
7) Uncontrolled sugars - Type 3C diabetes

Treatment given:

1.RT Feeds Milk,free water 100ml 4th hrly
2.IVF -NS,RL @100ml/hr
3.Inj.THIAMINE 100mg in 100ml NS/IV/TID
4.Inj.PAN 40mg IV/OD
5.Inj.ZOFER 4mg/IV/TID
6.Tab.FLUCONAZOLE 100mg/RT/OD
7.Syp.POTKLOR 15ml in one glass of water PO/BD
8.Inj.HAI S/C acc to GRBS
9.GRBS charting 6th hrly
10.BP/PR/TEMP CHARTING 4TH HRLY
11.STRICT I/O MONITORING












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