case 7 70 year old female with acute ischemic stroke(left MCA territory),? Cardioembolic stroke(heart failure with preserved ejection fraction with RBBB)

 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:

A 70 year old female came with 

c/o inability to speak since morning around 7:30 am

No h/o weakness of upper limb and lower limb 

No h/o deviation of mouth

No h/o giddiness/syncopal attack

No h/o fall/loss of consciousness/epilepsy

History of present illness:

Patient was apparently asymptomatic 1-2 hrs back then around at 7am patient son went to wake him up which was his usual time where he observed she was unable to speak but she was able to move her both upperlimbs and lowerlimbs on bed and there was no deviation of mouth.

She was not responding to commands but her eyes were open .

She was rushed to local rmp and was told low bp there for which she was given salt water and was referred to kamineni

Then she presented to our hospital only with inability to speak 

She was apparently normal previously where she did her daily routine

Yesterday she did her routine activities like watched tv,ate dinner and went to bed around 8pm 

There were no similar episodes in the past

Not k/c/o TB,DM,HTN,ASTHMA,CAD,EPILEPSY AND THYROID DISORDER

K/c/o hypotension based on attender words

Personal h/o : 

Married

Patient have mixed diet

Loss of appetite 

Bowel bladder movements normal 

No addictions 

O/e 

Patient is c/c/c

no pallor, icterus, cynosis, clubbing, lymphAdenopathy,pedal edema

Afebrile on touch 

PR - 72/min

BP - 150/100 mmHg

CVS S1S2 +

RS BAE +

P/A soft non tender 

CNS:

HMF 

Aphasia +

Not Oriented to time place person 

CRANIAL NERVES could not be elicited

MOTOR SYSTEM 

Power could not be elicited 

Tone:          

                         UL       Normal        Normal

                        LL      Normal         Normal

Bulk:    inspection       Normal          Normal

             palpation.        Normal          Normal

Reflexes:   

               B        T      S        K      A.   P

Right:     2+      2+      2+     2+      0   exten

Left:        2+      2+   2+      2+     0    exten











SENSORY  could not be elicited 

CEREBELLAR SIGNS  could not be elicited

Investigations:

hb:12.5mg/dl

tlc:10,000

Plt:2.08

pcv:36.3

Mcv:81.6

Mch:28.8

Mchc:35.3

troponin I:negative

CT Brain:

Hypodensity of 22-26 HU with loss of grey white matter differentiation involving left fronto parietal and temporal lobes and left basal ganglia(acute infarct of left MCA territory) 

No evidence of hemorrhage

no evidence of midline shift/mass effect






Ecg:






  



2d echo:


Chest x ray:



Treatment:

Ryles tube insertion

Foley's catheterisation

Rt feeds 100ml milk+protein 4th hrly

                50ml free water 4th hrly

Tab ecosporin gold/rt/hs

Inj optineuron 1amp in 100ml ns/iv/od

Bp charting 2nd hrly

Grbs charting 6th hrly



Day 2:

 No fresh complaints 

O/e: pt drowsy but arousable

GCS-E2V1M5

Afebrile

PR-75bpm

Bp-120/70mmhg

Input-700/1200ml

Grbs-122mg/dl

Cvs-s1,s2+

Rs-BAE+

P/A-soft,non tender

CNS:

Aphasia+

HMF: speech -

          Not Oriented to time/place/person

          Pupils b/l reacting to light +

          Memory: immediate -

                           Recent  -

                           Remote -

Cranial nerves:could not be elicited

Motor system:   

 Power could not be elicited 

Tone:          

                         UL       Normal        Normal

                        LL      Normal         Normal

Bulk:    inspection       Normal          Normal

             palpation.        Normal        Normal   

Reflexes:   

               B      T     S       K       A      P


Right:     -       -       -       -        -        Exten

Left:       +      -        -       -        -          exten

Sensory system: could not be elicited

Cerebellar signs:could not be elicited


Investigations:
Hemogram :
hb:12.5
tlc:10,000
plt:2.05

lipid profile:
Total cholesterol:203mg/dl
Triglycerides:127mg/dl
hdl:59.3mg/dl
ldl:117 mg/dl
vldl:25.4




Treatment:

Rt feeds 100ml milk+protein 4th hrly

                50ml free water 4th hrly

Tab ecosporin gold/rt/hs

Inj optineuron 1amp in 100ml ns/iv/od

Bp charting 8th hrly

Grbs charting 6th hrly




Day 3:

No fresh complaints 

O/e: pt drowsy but arousable

GCS-E2V1M5

Afebrile to touch

PR-82bpm

Bp-130/70mmhg

Input-950/900ml

Grbs-125mg/dl

Cvs-s1,s2+

Rs-BAE+

P/A-soft,non tender

CNS:

HMF: Aphasia+

          Not Oriented to time/place/person

          Pupils b/l reacting to light +

          Memory: immediate -

                           Recent  -

                           Remote -

Cranial nerves:could not be elicited

Motor system:   

 Power could not be elicited 

Tone:          

                         UL       Normal        Normal

                        LL      Normal         Normal

Bulk:    inspection       Normal          Normal

             palpation.        Normal       Normal   

Reflexes:   

               B      T     S       K       A      P


Right:     0       0       0       0       0       Exten

Left:       +       +       0       0       0        exten


Sensory system: could not be elicited

Cerebellar signs:could not be elicited

Investigations:


Treatment:

Rt feeds 100ml milk+protein 4th hrly

                50ml free water 4th hrly

Tab ecosporin gold/rt/hs

Inj optineuron 1amp in 100ml ns/iv/od

1 unit ns@50ml/hr (slow infusion) 

Bp charting 8th hrly

Grbs charting 6th hrly


Day 4:

No fresh complaints 

O/e: pt drowsy but arousable

GCS-E2V1M5

Afebrile to touch

PR-72bpm

Bp-130/70mmhg

Input-1400/1000ml

Grbs-110mg/dl

Cvs-s1,s2+

Rs-BAE+

P/A-soft,non tender

CNS:

HMF: Aphasia+

          Not Oriented to time/place/person

          Pupils b/l reacting to light +

          Memory: immediate -

                           Recent  -

                           Remote -

Cranial nerves:could not be elicited

Motor system:   

 Power could not be elicited 

Tone:          

                         UL       Normal        Normal

                        LL      Normal         Normal

Bulk:    inspection       Normal          Normal

             palpation.        Normal       Normal   

Reflexes:   

               B      T     S       K       A      P


Right:     3+       0       0       0       0       Exten

Left:       0       3+       0       0       0        exten


Sensory system: could not be elicited

Cerebellar signs:could not be elicited

Investigations :

Hb:11.9
Tlc:8,200
plt:1.20


Treatment:

soft oral diet

Oral fluids 2L/day

Tab ecosporin gold/rt/hs

Inj optineuron 1amp in 100ml ns/iv/od

1 unit ns@50ml/hr (slow infusion) 

Bp charting 8th hrly

Grbs charting 6th hrly


Day 5:

No fresh complaints 

O/e: pt drowsy but arousable

GCS-E2V1M5

Afebrile to touch

PR-72bpm

Bp-140/70mmhg

I/o:800/1200ml

Grbs-108mg/dl

Cvs-s1,s2+

Rs-BAE+

P/A-soft,non tender

CNS:

HMF: Aphasia+

          Not Oriented to time/place/person

          Pupils b/l reacting to light +

          Memory: immediate -

                           Recent  -

                           Remote -

Cranial nerves:could not be elicited

Motor system:   

 Power could not be elicited 

Tone:          

                         UL       Normal        Normal

                        LL      Normal         Normal

Bulk:    inspection       Normal          Normal

             palpation.        Normal       Normal   

Reflexes:   

               B      T     S       K       A      P


Right:     1+       0       0       0       0       Exten

Left:       2+       1+      0       2+     0     exten


Sensory system: could not be elicited

Cerebellar signs:could not be elicited



Treatment:

soft oral diet

Oral fluids 2L/day

Tab ecosporin gold/rt/hs

Inj optineuron 1amp in 100ml ns/iv/od

1 unit ns@50ml/hr (slow infusion) 

Bp charting 8th hrly

Grbs charting 6th hrly

Physiotherapy


Day 6:

No fresh complaints 

O/e: pt drowsy but arousable

GCS-E4V1M5

Afebrile to touch

PR-70bpm

Bp-120/80mmhg

I/o:1500/1800ml

Grbs-102mg/dl

Cvs-s1,s2+

Rs-BAE+

P/A-soft,non tender

CNS:

HMF: Aphasia+

          Not Oriented to time/place/person

          Pupils b/l reacting to light +

          Memory: immediate -

                           Recent  -

                           Remote -

Cranial nerves:could not be elicited

Motor system:   

 Power could not be elicited 

Tone:          

                         UL       Normal        Normal

                        LL      Normal         Normal

Bulk:    inspection       Normal          Normal

             palpation.        Normal       Normal   

Reflexes:   

               B      T     S       K       A      P


Right:     1+       0       0       0       0       Exten

Left:       2+       0        0       0       0     exten


Sensory system: could not be elicited

Cerebellar signs:could not be elicited



Treatment:

soft oral diet

Oral fluids 2L/day

Tab ecosporin gold/rt/hs

Inj optineuron 1amp in 100ml ns/iv/od

1 unit ns@50ml/hr (slow infusion) 

Bp charting 8th hrly

Grbs charting 6th hrly

Physiotherapy




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