case 19 - 58 year old male with right sided hemiplegia,acute hemorrhagic stroke ,hypertensive bleed in left frontoparietal lobe with midline shift to left

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Here is a case i have seen:

58 year old male,daily labourer by occupation came with

 c/o inability to move right upper and lower limb since yesterday evening 

Aphasia since yesterday evening 

Deviation of mouth to left side 

Altered sensorium +

History of present illness:

Patient was apparently asymptomatic till yesterday evening and was brought home by outside people around 6pm where there was a sudden history of fall with inability to lift right upper and lower limb with aphasia .

Patient attenders took the patient to nearby hospital where ct was done and was told intracranial bleed present and was referred to government hospital where he had one episode of ? Urinary incontinence.Due to lack of care,they presented to our opd with the above described complaints.

There was a similar complaint in past 2 years ago which presented as inability to move right hand ? Ischemic stroke(no documentation) and there he was diagnosed as hypertensive and prescribed medication. he used medication for few days and later discontinued as restoration of functions were noticed.

K/c/o hypertension since 2 years.

Not a k/c/o DM ,ASTHMA,TB ,CAD,epilepsy.

Patient is chronic alcoholic since 30 years daily whiskey 90-180 ml.

It was on the way to get alcohol he devoloped stroke.

H/o smoking (beedi) one pack per day since 30 years.

Patient has mixed diet.

Appetite is normal.

Bowel and bladder movements regular.

On examination:

Moderately built and moderately nourished

No pallor,icterus, cyanosis, clubbing,lymphadenopathy,edema.

GCS:E1V1M4

Pupils bilaterally reacting to light and equal in size.

Afebrile

BP:180/90mmhg

PR:84bpm

RR:15cpm

Systemic examination:

CVS- s1 s2 heard

RS- bilateral air entry present,normal vesicular breath sounds heard.

Per abdomen- scaphoid in shape,soft,non tender,bowel sounds present.

CNS-


Higher motor funtions:

Not oriented to time, place,person.

Speech-aphasia


cranial nerves- could not be elicited due to altered status



MOTOR SYSTEM 

                                        Right             Left

Bulk:    inspection       Normal          Normal

             palpation        Normal          Normal


Measurements  U/L   Equal on both sides

                          L/L   Equal on both sides


Tone:          

                         UL       hypertonia       Normal

                  

                        LL      hypertonia        Normal


Power : could not be elicited due to altered status

 

          

Reflexes:

Deep tendon reflexes

                                 Rt.                       Lt.

   Biceps                  3+                         2+

   Triceps                3+                          2+

   Supinator            3+                         2+

   Knee                     3+                        2+

   Ankle                    2+                      2+

Plantars - rt. Side  extensor

                 Lt. Side   flexor

 SENSORY SYSTEM - could not be elicited due to altered status.

                                 

CEREBELLAR SIGNS - could not be elicited due to altered status.


Outside ct report:


                  




Investigations:


CBP-

Hb:16.0

TLC:16,100

Plt. Count:2.20


LFT:

TB-2.51

DB-0.91

AST-37

ALT-17

ALP-208

TP-7.2

Albumin-4.2

A/G ratio-1.4


RFT:

Urea-53

Creat-1.2

Uric acid-7.4

Na-138

K-4.7

Cl-102


Serology-negative


BT-2min 30sec


CT-5min


CUE-

Albumin +

Pus cells -


CXR



              


Ecg-



          



Treatment given:


Inj.pan 40mg iv od

Inj.zofer 4 mg iv tid

Inj.optineuron 1 amp in 100ml NS iv od

Inj.mannitol 100ml iv tid

Inj.levipil 500mg iv bd

Ryles insertion

Foley's insertion

BP/PR/temp. Charting hrly

Grbs 8th hrly

Strict input/output charting

RT feeds 100ml (milk +protein powder)4th hrly

                 50ml free water 4th hrly

Tab.amlong 10mg po od


Ophthalmology referral done i/v/o papilledema.

They examined, 

   impression- normal fundus study,no               papilledema.


Day 2:


O/e

Pt. not oriented to time place,person,time

GCS-E1V1M4

Pupils-b/l reacting to light,equal in size

Temp-98.4

PR-80bpm

BP-180/100

I/o-1300/1100

CVS- s1 s2 heard

RS- bilateral air entry present,normal vesicular breath sounds heard.

Per abdomen- scaphoid in shape,soft,non tender,bowel sounds present.

CNS-


Higher motor funtions:

Not oriented to time, place,person.

Speech-aphasia


cranial nerves- could not be elicited due to altered status



MOTOR SYSTEM 

                                        Right             Left

Bulk:    inspection       Normal          Normal

             palpation        Normal          Normal


Measurements  U/L   Equal on both sides

                          L/L   Equal on both sides


Tone:          

                         UL       hypertonia       Normal

                  

                        LL      hypertonia        Normal


Power : could not be elicited due to altered status

 

          

Reflexes:

Deep tendon reflexes

                                 Rt.                       Lt.

   Biceps                  3+                         2+

   Triceps                3+                          2+

   Supinator            3+                         2+

   Knee                     3+                        2+

   Ankle                    2+                      2+

Plantars - rt. Side  extensor

                 Lt. Side   flexor

 SENSORY SYSTEM - could not be elicited due to altered status.

                                 

CEREBELLAR SIGNS - could not be elicited due to altered status.


Investigations:


FBS-177


HbA1c- 6.7


Na-143

K-3.7

Cl-97


FLP-

Total cholesterol-198

Triglycerides-123

HDL-58

LDL-112

VLDL-24.6


2d echo :

No regional wall motion abnormality

Trivial TR+, no MR, no AR

Sclerotic AV 

Good LV sysytolic function

EF-58

Diastolic dysfunction

IVC size : 1.3 cms


Treatment given-


Head end elevation upto 30 degrees

Air or water bed

Inj.pan 40mg iv od

Inj.zofer 4 mg iv tid

Inj.optineuron 1 amp in 100ml NS iv od

Inj.levipil 500mg iv bd

BP/PR/temp. Charting hrly

Grbs 8th hrly

Strict input/output charting

RT feeds 100ml (milk +protein powder)4th hrly

                 50ml free water 4th hrly

Tab.amlong 10mg po od


Day 3


O/e

Pt. not oriented to time place,person,time

GCS-E1V1M4

Pupils-b/l reacting to light,unequal in size

Temp-98.4

PR-87bpm

BP-160/90

I/o-1000/1100

CVS- s1 s2 heard

RS- bilateral air entry present,normal vesicular breath sounds heard.

Per abdomen- scaphoid in shape,soft,non tender,bowel sounds present.

CNS-


Higher motor funtions:

Not oriented to time, place,person.

Speech-aphasia


cranial nerves- could not be elicited due to altered status



MOTOR SYSTEM 

                                        Right             Left

Bulk:    inspection       Normal          Normal

             palpation        Normal          Normal


Measurements  U/L   Equal on both sides

                          L/L   Equal on both sides


Tone:          

                         UL       hypertonia       Normal

                  

                        LL      hypertonia        Normal


Power : could not be elicited due to altered status

 

          

Reflexes:

Deep tendon reflexes

                                 Rt.                       Lt.

   Biceps                  3+                         2+

   Triceps                3+                          2+

   Supinator            3+                         2+

   Knee                     3+                        2+

   Ankle                    2+                      2+

Plantars - rt. Side  extensor

                 Lt. Side   flexor

 SENSORY SYSTEM - could not be elicited due to altered status.

                                 

CEREBELLAR SIGNS - could not be elicited due to altered status.


MRI brain was done.


                     



          





         





          


 



         


Pt. was referred to neurological centre i/v/o midline shift(8mm).

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