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).
Comments
Post a Comment