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

  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

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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