A 35yr old male with slurring of speech and difficulty in walking

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A 35yr old male came to the hospital with chief complaints of:

1. slurred speech since yesterday night,

2. Tingling sensation of bilateral upoer and lower limbs since yesterday night .

3. Difficulty in walking associated with diplopia since yesterday night 

History of fall from bed yesterday night at 3am and was hit to a hard object from then he developed slurred speech and difficulty in walking. 

He was apparently asymptomatic since yesterday when he had a history of fall from bed yesterday night at 3am and was hit to a hard object from then he developed slurred speech and difficulty in walking. Along with which the was tingling sensation in bilateral upper and lower limbs .

Intake of phenytoin 100mg(60tablets)on 2nd of September for suicidal attempt.

Past history of sucudal attampts :

1.10yrs back

2.10 days back with 10tablets of phenytoin (did not revel till 2days of admission).

No bowel and bladder incontinence., 

No h/o nausea, vomiting, fever, chestpain, palpitations, blurring of vision, burning micturition

No injuries to spine and no tenderness in spine region

K/c/o seizures since 12years on regular medication on phenytoin. Since past 8months he is on levipill.

Not a k/c/o DM, HTN, ASTHMA

,TB.

no habits of alcohol intake or smoking.

No similar complaints in the past ., no past surgical history.

GENERAL EXAMINATION-

Patient is conscious, coherent and cooperative.

Moderately built and nourished.

Vitals -  

Temp- Afebrile 

Bp- 160/110mmHg

PR- 78bpm

RR- 18cpm 

Pallor +, icterus, cyanosis , clubbing, pedal edema, lymphadenopathy.

SYSTEMIC EXAMINATION:

PER ABDOMEN-

Shape - scaphoid 

No Tenderness and local rise of temperature

No palpable mass 

No organomegaly

Hernial orifices free

Bowel sounds present

RS- 

Position of trachea central

NVBS +

No wheeze 

No adventitious breath sounds 

CVS- 

S1S2 heard

No murmurs 

Apex beat not felt

CNS-

Pt is C,C oriented to T/P/P Right handed person

Speech- Slow, slurred, unintentional pauses present(Improved)

MMSE-29/30

1. Orientation- 5/5, 5/5 

2. Registration- 3/3 

3. Recall- 3/3

4. Attention & Calculation- 5/5

5. Language- 2/2

Cranial Nerve Examination

I - Sense of smell- N

II- a. visual acuity-N

   b. Field of vision-N

   c. Colour vision-N

   d. Fundus-N

III, IV, V- a) EOM movements-both rt and lt normal

                b) pupil size-2-3mm

                c) Direct light reflex/ Consensual reflex/ accomadation reflex +

                d) Ptosis -

                e) Nystagmus PRESENT(Horizontal).

V         Sensory-Overface & busal mucosa- normal

            Motor-Masseter, Temporalis, pterygoid-normal

            Reflexes-Corneal, Conjunctival- normal

                  Jaw jerk not present.

VII       Motor

            1. Naselabial fold           Equal on both sides

            2. occipitofrontalis         +

            3. Orbiculasis oculi         +

            4. Oribiculas oris             +

            5. Buccinator                   +

           Sensory

            1. Taste over anterior 2/3 rd of tongue +

VIII      Rinnes test- Could not perform

            Webers test -Could not perform

IX, X    1. Uvula Central, Palatal arclus- Equal, Movements

            2. Gag reflex +

            3. palatal reflex+

XI         1. Trapezius - shrugging of shoulders present

             2. Sternocleilomastoid -normal

XII 1. wasting -no

     2. Fasciculation- no

     3. tongue profusion to mid line

Motor system examination

Power

U/L 

                                                       Right       Left

Shoulder- Flexion-Extension-5/5              5/5

                   Lateral-Medinlatation-5/5        5/5

                   Adduction-Abduction-5/5          5/5

                   Pronation-Supination-5/5           5/5

Elbow and wrist -5/5

Hand Grip-100% on both sides

L/L

                                              Rt                     Lt

 Hip- Flexion-Extension-5/5                      5/5

          Lateral-Medinlrotation-5/5              5/5

          Adduction-Abduction-5/5                  5/5

          Pronation-Supination-5/5                  5/5

Knee- Flexion-Extension-5/5                        5/5

Ankle- Dorsiflusion-planter flusion-5/5      5/5

             Inversion-Eversion-5/5                      5/5

Trunk muscles- Rolling over bed-Can perform

Superficial reflexes

1. Corneal +

2. Conjunctival +

3. Phayayeal +

4. Palateal +

5. Abdominal +

6. Cremasteric +

Deep tender refection

                         Rt                 lt

1. Biceps +                    +

2. Triceps ++                 ++

3. Sipinator -                 -

4. Knee -                          -

5. Ankle -                         -

Cerebellar Examination

1. Finger nose test -

2. Finger nose finger test -

3. Dysdindokinesia -

4. Heel knee test -

5. Tanders walking- cannot be done

Sensory System Examination

Spinothalamic

1. Crude touch +

2. Pain +

3. Temperature +

Posterior Column

1. Fine touch +

2. Vibration -

3. Position sense+

Cortical

1. Two point discrimination -

2. Tartile localisation+

3. Graphosthesia+

4. Sterogenosis+

Gait-

Examination of spine->N

Examination of other systems- NAD(+)

INVESTIGATIONS:

CBP:

PERIHERAL SMEAR:

SR.MAGNESIUM

RBS:

RFT:

ECG:

2DECHO:

MRI BRAIN:

DIAGNOSIS:

      Cerebellar ataxia secondary to phenytoin toxicity with k/c/o epilepsy (GTCS)with self harm behaviour (suicidal tendencies).

TREATMENT:

1.Tab.LEVIPILL (500MG) BD/PO

2.TAB.NEXITO10MG OD/PO X-X-1

3.TAB .CLONAZEPAM 0.5mg OD /HS X-X-1

4.TAB.MVT OD/2PM

5.Monitor vitals pr/bp/spo2 hrly.