50M AIS ; CVA; DM ; HTN

 Case History and Clinical Findings

50 YEAR OLD WHO IS RESIDENT OF CHERUVUGATTU CAME WITH COMPLAINTS IF WEAKNESS OF LEFT U/L AND L/L SINCE TODAY MORNING

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC TILL TODAY MORNING THEN ATTENDERS NOTICED THAT PATIENT WAS UNABLE TO GET UP FROM THE BED AND COMPLAINTS OF WEAKNESS IN LEFT U/L AND L/L WHICH WAS SUDDEN IN ONSET AND GRADUALLY PROGRESSIVE

NO H/O LOC

NO H/O OF INVOLUNTARY MOVEMENTS AND DROOLING OF SALIVA

NO H/O OF INVOLUNTARY MICTURATION AND DEFECATION

PAST ILLNESS:-

K/C/O OF ACUTE CVA (RT HEMIPARESIS) IN 2020 JULY

K/C/O HTN AND DM SINCE 2YEARS ANDF ON REGULAR MEDICATION (TAB.METFORMIN 500MG +GLIMIPERIDE 1MG PO/OD, TAB.METFORMIN 500MG PO/OD NIGHT AND TAB.AMLONG 2.5MG PO/OD

PERSONAL HISTORY:

DIET-MIXED

APPETITE -NORMAL

BOWEL AND BLADDER - REGULAR

SLEEP-ADEQUATE

ADDICTIONS- HE WAS A CHRONIC ALCHOLIC SINCE 30 YRS ,STOPPED 2 YEARS BACK ,AFTER RIGHT HEMIPLEGIA

HE CHEWS TOBACCO SINCE 20 YRS AND STOPPED 2YRS BACK.

ALLERGIES- NONE

FAMILY HISTORY:

INSIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS CONSIOUS ,COHERENT ,COPERATIVE

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY

VITALS:

TEMP-97.2F

BP- 110/70MMHG

PR-72 BPM

RR-16CPM

SPO2-97% AT ROOM AIR

GRBS:164

SYSTEMIC EXAMINATION:

CVS-S1 S2 HEARD NO MURMURS

RS-BAE+ NVBS

P/A -SOFT NON TENDER,NO GUARDING,NO RIGIDITY, HERNIAL ORIFICES NORMAL

CNS EXAMINATION:- 
B/L PUPILS NSRL
TONE :RIGHT LEFT
U/L HYEPR HYPO
L/LHYEPR HYPO
POWER:RIGHT LEFT
U/L 3/5 0/5
L/L 3/5 0/5
SUPERFICIAL REFLEXES - CORNEAL /CONJUNCTIVAL REFLEX- NORMAL
ABDOMINAL REFLEX -NORMAL
DEEP REFLEXES
JAW JERK -PRESENT
RL
BICEPS +2 +2
TRICEPS +1 +1
SUPINATOR +1 +1
KNEE +2 +2
ANKLE +1 +1
PLANTAR FLEXOR EXTENSOR
SENSORY EXAMINATION COULDN'T BE ELICITED

COURSE IN HOSPITAL:-
PATIENT IS ADMITTED I/V/O WEAKNESS OF LEFT U/L AND L/L SINCE MORNING ON 05/05/23.ON FURTHER EVALUATION MRI- FOUND TO HAVE ACUTE INFARCT IN RIGHT SUPERIOR PARIETAL LOBULE,SUPERIOR FRONTAL GYRUS,CENTRUM SEMIOVALE,PERIVENTRICULAR WHITE MATTER- EXTERNAL WATERSHED TERRITORY INFARCT
ENCEPHALOMALACIA WITH GLIOTIC CHANGES IN LEFT FRONTAL LOBE EXTENDING TO PERIVENTRICULAR WHITE MATTER
K/C/O RIGHT HEMIPARESIS IN 2020

ON ADMISSION
GCS- E2V2M53

O/E:-

BP- 130/80MMHG
PR-90 BPM
RR-20CPM
SPO2-97% AT ROOM AIR
SYSTEMIC EXAMINATION:
CVS-S1 S2 HEARD NO MURMURS
RS-BAE+ NVBS
P/A -SOFT NON TENDER,NO GUARDING,NO RIGIDITY, HERNIAL ORIFICES NORMAL
CNS EXAMINATION
B/L PUPILS NSRL
TONE :RIGHT LEFT
U/L HYEPR HYPO
L/LHYEPR HYPO
POWER:RIGHT LEFT
U/L 3/5 0/5
L/L 3/5 0/5
SUPERFICIAL REFLEXES - CORNEAL /CONJUNCTIVAL REFLEX - NORMAL
ABDOMINAL REFLEX - NORMAL
DEEP REFLEXES
JAW JERK -PRESENT
RL
BICEPS +2 +2
TRICEPS +1 +1
SUPINATOR +1 +1
KNEE +2 +2
ANKLE +1 +1
PLANTAR FLEXION EXTENSION
ON 6/5/23 OPTHALMOLOGY REFERRAL WAS DONE
REVIEWED I/V/O DIABETIC& HYPERTENSIVE RETINOPATHY CHANGES AND ALSO RAISED ICP FEATURES
IMPRESSION:NORMAL ANTERIOR SEGMENT ,NO VIEW BECAUSE OF THICK POSTERIOR SUBCAPSULAR CATARACT, TLC COUNT STARTED INCREASING AND WAS INITIALLY STARTED ON INJ MONOCEF AND THEN
LATER ESCALATED TO PIPTAZ AND CLINDAMYCIN
WITH ?ASPIRATION PNEUMONIA (RESOLVED)
ON 6/05/23 KERNINGS SIGN- POSITIVE BRUDZINKI SIGN- POSITIVE AND SO LUMBAR PUNCTURE WAS DONE ON THE SAME DAY.
CSF ANALYSIS SHOWED NO CELLS
CSF CULTURE AND SENSITIVITY- NO GROWTH AFTER 24HRS OF AEROBIC INCUBATION.
BLOOD C/S- NO GROWTH AFTER 24 HRS OF AEROBIC INCUBATION.
URINE C/S -E.COLI >10 POWER 5 CFU/ML OF URINE ISOLATED

0N 9/05/23 -X RAY CHEST AP VIEW
-CONSOLIDATORY CHANGES NOTED IN THE RIGHT LATERAL ASPECT OF MID AND LOWER ZONE OF LUNG,WE ESCALATED ANTIBIOTIC 

9/5/23 PULMONOLOGY REFERRAL WAS DONE I/V/O-CONSOLIDATORY CHANGES IN THE RIGHT LATERAL ASPECT OF MID AND LOWER ZONE OF LUNG. AND WAS ADVISED T.MUCINAC 600 MG TID RT AND ON THE SAME DAY THERE WAS SUDDEN FALL IN SPO2 LEVELS &THERE WAS IMPENDING DECISION FOR INTUBATION BUT LATER SPO2 MAINTAINED. AND WITH RIGHT MIDDLE&LOWER ZONE CONSOLIDATION[RESOLVING] WITH ACUTE LIVER INJURY[RESOLVING].

NEUROLOGY REFERRAL DONE ON 11/05/23 AND WAS ADVICED TO CONTINUE SAME MEDICATION AND ALSO ADDED CLOPIDOGREL, EXPLAINED POOR PROGNOSIS.
TODAY ON 15/03/23 ,
PRESENTLY ON DAY OF DISCHARGE
GCS- E3V2M3
BP- 120/80MMHG
PR-112BPM
RR-40CPM
SPO2-100% @ RA

SYSTEMIC EXAMINATION:

CVS-S1 S2 HEARD NO MURMURS
RS-BAE+ NVBS WITH B/L GRUNTING
P/A -SOFT NON TENDER,NO GUARDING,NO RIGIDITY, HERNIAL ORIFICES NORMAL

CNS EXAMINATION:-

B/L PUPILS NSRL
TONE :RIGHT LEFT
U/L HYEPR HYPO
L/LHYEPR HYPO
POWER:RIGHT LEFT
U/L 3/5 0/5
L/L 3/5 0/5
SUPERFICIAL REFLEXES - CORNEAL /CONJUNCTIVAL REFLEX- NORMAL
ABDOMINAL REFLEX -NORMAL
DEEP REFLEXES
JAW JERK -PRESENT
RL
BICEPS +2 +2
TRICEPS +1 +1
SUPINATOR +1 +1
KNEE +2 +2
ANKLE +1 +1
PLANTAR FLEXION EXTENSION

COURSE AT HOSPITAL:-

OPHTHALMOLOGY REFERRAL DONE ON 06/5/23

IMPRESSION: NORMAL ANTERIOR SEGMENT. FUNDUS-NO VIEW BECAUSE OF THICK POSTERIOR SUBCAPSULAR CATARACT
PULMONOLOGY REFERRAL DONE ON 23/5/23
1.CST
2.NEBULISATION WITH BUDECORT 12TH HOURLY ,IPREVENT 8TH HOURLY ,MUCOMIST 8TH HOURLY
3.TAB. PCM 650MG PO/BD
4.HIGH PROTEIN DIET - 2 SPOONS OF PROTEIN POWDER IN 1 GLASS OF WATER THROUGH RT

SURGERY REFFERAL DONE ON 17/5/23
1.CST
2.FREQUENT CHANGE OF POSTURE
3.PRESSURE DRESSING WITH MEGAHEAL
4.REVIEW SOS

SURGERY REFFERAL DONE ON 27/5/23
1.REGULAR CHANGE OF POSTURE
2.ALPHA BED
3.AMBULATION OF B/L LOWER LIMBS
4.CST AS PRESCRIBED

SURGERY REFFERAL DONE ON 29/5/23
1.CHANGE IN POSTURE
2.ASD AND MEGAHEAL
3.ALPHA BED

SURGERY REFFERAL DONE ON 03/6/23
1.2ND HOURLY POSITION CHANGE
2.AVOID CONTAMINATION OF WOUND
3.MOVEMENT OF ALL FOUR LIMBS
4.DVT PROPHYLAXIS

SURGERY REFFERAL DONE ON 04/6/23
1.2ND HOURLY POSITION CHANGE
2.AVOID CONTAMINATION OF WOUND
3.MOVEMENT OF ALL FOUR LIMBS
4.DVT PROPHYLAXIS

SURGERY REFFERAL DONE ON 07/6/23
1.2ND HOURLY POSITION CHANGE
2.. PHYSIOTHERAPY OF ALL FOUR LIMBS
3.CST

Provisional Diagnosis:-
LEFT HEMIPLEGIA SECONDARY TO ACUTE INFARCT IN RIGHT SUPERIOR PARIETAL LOBULE,SUPERIOR FRONTAL GYRUS WITH RIGHT MIDDLE&LOWER ZONE CONSOLIDATION[RESOLVED] WITH ACUTE LIVER INJURY[RESOLVED] WITH UTI[RESOLVED] WITH CKD
K/C/O RIGHT HEMIPARESIS IN 2020
K/C/O DM II SINCE 2 YRS WITH GRADE III BEDSORE ON RIGHT AND LEFT BUTTOCKS AND NATAL CLEFT

 Investigation:-

HAEMOGRAM-5/5; 7/5 ;8/5;9/5;10/5;11/5;12/5;13/5;14/5;15/5;16/5;16/5;17/5;18/5;19/5;20/5;21/5;22/5;23/5;24/5;25/5;26/5;27 /5;28/5;29/5;30/5;31/5;01/6;02/6;03/6;04/6;06/23;07/23
HB:14.3;14.7;14.8;13.3;;12.6;11.9;12.1;11.2;11.9;12.0;11.9;11.8;12.4;11.3;10.4;10.3;9.9;10.4;10.2;9. 5;9.5;9.1;8.6;8.4;8.1;8.0;7.7;7.6;7.2;7.1;6.7
TLC:9,000;13,800;13,800;12;300;11,600;11,000;11,000;15,000;13,400;28000;26600;25100;27300;23 700;19100;
15100;12900;14300;19600;18100;17400;16600;13500;11900;12200;11000;11000;10900;13300;13,9 00;14,100
PCV:43.7;81.0;45.7;40.3;38.1;36.8;38.2;36.3;37.8;37.5;36.1;36.5;36.9;34.6;32.9;32.5;30.3;31.8;32.0; 28.8;29.3;28.3;26.3;26.3;25.6;26.1;24.7;25.0;23.2;23.7;22.3
MCV:81.4;81.0;81.3;81.1;81.8;83.3;84.1;85.8;84.9;90.0;81.8;82.4;81.4;81.7;81.7;80.4;81.7;81.8;85.0; 84.3;85.0;84.1,84.5
MCH:26.6;26.6;26.3;26.8;26.0;26.9;26.7;26.5;26.7;27.0;26.9;27.4;26.8;26.9;26.8;26.7;25.4;26.1;26.7; 26.3;26.3;30.4;26.1;25.4
RBC COUNT:5.37;5.53;5.62;4.97;4.66;4.42;4.54;4.23;4.45;4.47;4.42;4.43;4.54;4.24;3.86;3.84;3.72;4.08;3. 92;3.58;3.61;3.46;3.31;3.22;3.13;3.07;4.60;2.76;2.81;2.64
PLT:2.01;2.11;2.27;2.37;2.2;2.43;2.95;3.12;3.24;2.81;3.28;3.10;3.90;3.91;4.29;3.95;4.25;4.43;4.0;3.0; 4.15;4.09;3.94;4.2;4.0;2.93;4.0;3.87;3.48;3.84 

CSF CYTOLOGY 6/5/2023:NO CELLS SEEN
CSF CULTURE AND SENSITIVITY-
BLOOD C/S- NO GROWTH AFTER 24 HRS OF AEROBIC INCUBATION.
URINE C/S -E.COLI >10 POWER 5 CFU/ML OF URINE ISOLATED
X RAY CHEST AP VIEW
-CONSOLIDATORY CHANGES NOTED IN THE RIGHT LATERAL ASPECT OF MID AND LOWER ZONE OF LUNG.

USG ABDOMEN AND PELVIS (5/5/23)
RAISED ECHOGENICITY OF LEFT KIDNEY GRADE 1 FATTY LIVER

USG ABDOMEN AND PELVIS (8/5/2023)
RAISED ECHOGENECITY OF B/L KDINEYS

USG ABDOMEN AND PELVIS (24/5/23)
B/L RENAL CORTICAL CYSTS

2D ECHO:-
EF -67%
-MILD TR WITH PAH ;MILD AR;NO MR
-NO RWMA .NO AS/MS,SCLEROTIC AV
-GOOD LV SYSTOLIC FUNCTION
-DIASTOLIC DYSFUNCTION ,NO PE

REVIEW 2D ECHO-
NO RWMA CONCENTRIC LVH
TRIVIAL TR/AR;NO MR
SCLEROTIC AV,NO AS/MS
EF 66%,RESP-35MMHG
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION,NO PAH/PE
IVC SIZE [1.16CMS] COLLAPSING

CAROTID ARTERY DOPPLER(8/5/2023)
RAISED CIMT IN B/L CCA'S
B/L CCA AND ICA NORMAL BIPHASIC WAVES,PATTERN CALIBRE AND COLOUR UPTAKE
NO E/O PLAQUES IN B/L CCA'S OR ICA'S

MRI BRAIN (05/5/23)
ACUTE INFARCT IN RIGHT SUPERIOR PARIETAL LOBULE,SUPERIOR FRONTAL GYRUS ,CENTRUM SEMIOVALE ,PERIVENTRICULAR WHITE MATTER-EXTERNAL WATERSHED TERRITORY INFARCT
ENCEPHALOMALACIA WITH GLIOTIC CHANGES IN LEFT FRONTAL LOBE EXTENDING TO ,PERIVENTRICULAR WHITE MATTER

Treatment Given(Enter only Generic Name)
1.IVF-2NS,1RL@75ml/hr
2.INJ.CLEXANE 40MG/SC/OD
3.INJ.HUMAN ACT RAPID INSULIN S/C IF GRBS >200MG/DL
4.INJ MONOCEF 1GM IV/BD X 3DAYS
5. INJ PIPTAZ IV BD X 7DAYS
6.INJ CLINDAMYCIN IV TID X 7DAYS
7.INJ MEROPENEM IV BD X 7DAYS
8.RT FEEDS @100ML WATER EVERY 2HRLY
@200ML MILK EVERY 4TH HOURLY ALONG WITH 2 SPOONS OF PROTEIN POWDER
9.TAB.NICARDIA 10MG SOS
10.TAB AMLONG 5MG RT/OD
11.TAB OROFER XT RT/BD
12.TAB NODOSIS 500MG RT / BD
13.TAB UDILIV 300MG RT/BD
14.SYP LACTULOSE 15ML RT/BD
15.OINT.MEGAHEAL FOR L/A OVER BED SORE
16.NEBULISATION WITH IPRAVENT 6TH HOURLY ,BUDECORT 12TH HOURLY ,MUCOMIST 6TH HOURLY
17.CHEST PHYSIOTHERAPY BEFORE EVERY FEED
18.PHYSIOTHERAPY -PASSIVE MOVEMENTS&STRETCHING
19.FREQUENT CHANGE OF POSITION EVERY 2HRLY

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