70/ M BROUGHT WITH INVOLUNTARY MOVEMENTS OF LEFT UPPER AND LOWER LIMBS FOLLOWED BY UNCONSCIOUSNESS 15 DAYS AGO

 70/ M with recurrent CVA 

CHIEF COMPLAINTS:

70 YEAR OLD MALE BROUGHT TO CASUALTY BY HIS ATTENDERS WITH COMPLAINTS OF INVOLUNTARY MOVEMENTS OF LEFT UPPER AND LOWER LIMBS FOLLOWED BY UNCONSCIOUSNESS 15 DAYS AGO

HISTORY OF PRESENT ILLNESS:

• PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS AGO THEN HE

HAD EPISODE OF INVOLUNTARY MOVEMENTS OF LEFT UPPER AND

LOWER LIMBS FOLLOWED BY UNCONSCIOUSNESS, SUDDEN IN ONSET RAPIDLY PROGRESSIVE NOT ASSOCIATED WITH VOMITINGS, FEVER, DEVIATION OF MOUTH, TONGUE BITE, INVOLUNTARY MICTURITION AND DEFECATION, FROTHING AND UP ROLLING OF EYES.

NO HISTORY CHEST PAIN, PALPITATIONS, BREATHLESSNESS EXCESSIVE SWEATING, COUGH COLD, PAIN ABDOMEN, ABDOMINAL DISTENSION, FACIAL PUFFINESS, DECREASED URINE OUTPUT PATIENT WAS INTUBATED ON DAY 3 OF ADMISSION IN VIEW OF EPILEPTICUS IN OUTSIDE HOSPITAL, ON DAY TRACHEOSTOMY WAS DONE AND ON MECHANICAL VENTILATOR

PAST HISTORY:

• NO SIMILAR COMPLAINTS IN THE PAST.

KNOWN CASE OF CVA SINCE 1 YEAR, USING MEDICATION.

KNOWN CASE OF TYPE 2 DM SINCE 3 YEARS, ON IRREGULAR MEDICATION

NOT A K/C/O HTN, CAD, BRONCHIAL ASTHMA, THYROID DISORDER, TB, EPILEPSY

PERSONAL HISTORY:

MIXED DIET

APPETITE NORMAL

REGULAR BOWEL AND BLADDER

KNOWN ALCOHOLIC SINCE 20 YEARS

NON SMOKER

NO SLEEP DISTURBANCES.

FAMILY HISTORY

• NO SIGNIFICANT FAMILY HISTORY.

GENERAL EXAMINATION:

PATIENTS IS ON MECHANICAL VENTILATOR.

MODERATLY BUILT AND NOURISHED

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPTHY,

EDEMA OF RIGHT UPPER LIMB SINCE 4 DAYS

• VITALS:

BP: 130/80 mmHg

22 CPM

TEMPERATURE:101 F

PR:115/MIN RR:

SPO2: 95% ON FIO2 30% GRBS: 183Mg/dl

CNS EXAMINATION:

GCS-E2V1M1

PUPILS-NORMAL IN SIZE

BILATERAL REACTIVE TO LIGHT.

• CORNEAL CONJUNCTIVAL REFLEXES-PRESENT

DOLLS EYE REFLEX-PRESENT

HIGHER MENTAL FUNTIONS CANT BE ELICITED

SENSORY SYSTEM CANT BE ELICITED.

NECK STIFFNESS ABSENT.

KERNIG AND BRUDZINSKI SIGN ABSENT.

RESPIRATORY EXAMINATION:

INSPECTION-CHEST IS ELLIPTICAL, BILATERAL SYMMETRICAL TRACHEA IS CENTRAL

MOVEMENTS OF CHEST BILATERALLY EQUAL

NO SCARS, SINUSES OR VISIBLE PULSATIONS

PALPITATIONS: ALL INSPECTORY FINDINGS ARE CONFIRMED

BILATERAL EQUAL MOVEMENTS

PERCUSSION: ALL AREAS ARE RESONANT ON PERCUSSION

AUSCULTATION: BILATERAL AIR ENTRY PRESENT, CREPITIS PRESENT IN RIGHT MA, IAA, IT IAA

CVS EXAMINATION:

• S1S2 HEARD

• NO MURMURS

PER ABDOMEN:

INSPECTION:- SCHAPHOID SHAPE, NO VISIBLE PULSATION/ ENGORGED VEINS/ SCARS/SINUSES.

• SOFT ON PALPATION

AUSCULTATION-BOWEL SOUNDS HEARD-8/min

PROVISIONAL DIAGNOSIS:

?RECURRENT CVA

SEPSIS

K/C/O DM II

S/P TRACHEOSTOMY(DAY 10)

POST INTUBATION DAY-17

INVESTIGATIONS:

MRI: ACUTE LACUNAR INFARCT IN LEFT SIDE OF PONTO MESENCEPHALIC JUNCTION

MILD VOLUME LOSS WITH SUB CORTICAL HYPER INTENSITY IN RIGHT FRONTO PARIETAL SUB CORTICAL WHITE MATTER LIKELY GLIOSIS SECONDARY TO OLD CVA

CHRONIC LACUNAR INFARCT IS SEEN IN LEFT THALAMUS AND PUTAMEN

• A TINY BLOOMING FOCUS SEEN IN RIGHT HEMI PONS? SMALL CALCIFIC FOCUS /? HYPERTENSIVE MICRO HEMORRHAGE.

AGE APPROPRIATE CEREBRAL ATROPHY

ET TUBE SWAB

BLOOD CULTURE 

SWAB FROM TRACHEOSTOMY 

FINAL DIAGNOSIS:

• RECURRENT CVA WITH (PONTINE INFARCT) WITH ISCHEMIC SEIZURES WITH METABOLIC ENCEPHALOPATHY WITH SEPSIS; NON OLIGURIC AKI (RESOLVED) WITH TYPE I RESPIRATORY FAILURE? HOSPITAL ACQUIRED PNEUMONIA; GRADE II BED SORES @ GLUTEAL REGION; K/C/O CVA SINCE 1 AND YEARS; K/C/O TYPE II DM SINCE 1 YEAR, S/P TRACHEOSTOMY DAY-12; DENOVO HTN+, POST INTUBATION DAY-20

TREATMENT GIVEN:

• RT FEEDS

IV FLUIDS 2 PINT NS @ 75 ML/HR

ENGINEERING. PIPTAZE 2.25gm IV QID FOR 7DAYS INJ PANTOP 2.25 GM 40 mg IV/OD

• INJ. LEVIPIL 1 G IV/BD

• INJ. GLYCOPYRROLATE 2 ML IV/SOS

INJ. HAI SC/TID BEFORE MEAL 6U-6U-4U

• INJ. NEOMOL 1G IV/ SOS (IF TEMP> 101 F)

• INJ. OPTINEURON 1 AMP IN 100 ML NS TAB. CLOPITAB 75 MG PO/HS RT/HS

TAB. STROCIT PLUS 800/500 MG RT/BD

TAB. CINOD 10 MG RT/OD

TAB. MET-XL 12.5 G RT/OD

TAB THIAMINE 200 MG IN 100 ML NS IV/BD

TAB. LIBRIUM 25 MG RT/TID

OINT. MEGAHEAL FOR LOCAL APPLICATIN OVER BEDSORE.

GRBS 7 POINTS PROFILE

AIR BED

POSITION CHANGE 2nd HOURLY

DAILY BEDSORE DRESSING WITH NEOSPORIN POWDER

PHYSIOTHERAPY OF ALL LIMBS

WATCH FOR SEIZURE ACTIVITY

• LIMB ELEVATION