202319751

 

 

 


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

 

R L

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

 

R L

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

 

R L

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

 

 

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.   VF-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

Advice at Discharge

INJ.HUMAN ACT RAPID INSULIN S/C IF GRBS >200MG/DL RT FEEDS @100ML WATER EVERY 2HRLY

@200ML MILK EVERY 4TH HOURLY ALONG WITH 2 SPOONS OF PROTEIN POWDER TAB.NICARDIA 10MG SOS

TAB.ECOSPIRIN AV 75/10 RT/OD TAB AMLONG 10MG RT/OD

TAB OROFER XT RT/BD FOR 30 DAYS TAB NODOSIS 500MG RT/ BD

OINT.MEGAHEAL FOR L/A OVER BED SORE.

NEBULISATION WITH IPRAVENT 6TH HOURLY ,BUDECORT 12TH HOURLY ,MUCOMIST 6TH HOURLY

CHEST PHYSIOTHERAPY BEFORE EVERY FEED PHYSIOTHERAPY -PASSIVE MOVEMENTS&STRETCHING FREQUENT CHANGE OF POSITION EVERY 2HRLY REGULAR DRESSING FOR BED SORE


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