case 35 : 80 YEAR OLD MALE WITH ALTERED SENSORIUM
80 YEAR OLD MALE WITH ALTERED SENSORIUM
21st April, 2022
thanks Dr. amatul
ICU ADMISSION
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- altered sensorium since afternoon
- aphasia, right upper limb weakness since 5 'o clock in the evening
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic till 12:30pm today. After 12:30pm, patient first complained of weakness followed by inability to walk and then slowly the weakness started worsening and by 5:00pm in the evening, the patient could not speak and could not move his right upper limb and from 6:00pm, the patient had c/o incontinence of urine
PAST HISTORY :
Not a k/c/o hypertension, diabetes, asthma, epilepsy, TB, thyroid
PERSONAL HISTORY :
Diet - mixed
Sleep - adequate
Appetite - normal
Alcoholic - abstinence from alcohol since 4years
GENERAL EXAMINATION :
Patient is drowsy
No pallor, icterus, cyanosis, lymphadenopathy
BP - 140/70 mm Hg
PR - 101 bpm
RR - 17 cpm
Spo2 - 94% on RA
GRBS - 133 mg/dl
Systemic examination :
CVS - S1 S2 +
RS - BAE+
P/A - soft, nontender
CNS -
Patient is drowsy
Spontaneous movements of left upper and lower limbs
Right upper limb - no movements
Right lower limb - decreased movements
Tone -
. Left upper and lower limbs : normal
. Right upper limb : hypotonia
. Right lower limb : hypertonia
Reflexes - Right Left
. Biceps : 2+ 2+
. Triceps : 2+ 2+
. Supinator : 2+ 2+
. Knee : absent absent
. Ankle : absent absent
. Plantar : mute mute
INVESTIGATIONS :
SEROLOGY - NEGATIVE
DIAGNOSIS :
- MULTIPLE INFARCTS IN LEFT MCA, ACA
- AF WITH FVR
- CARDIOEMBOLIC STROKE
TREATMENT :
1. TAB ECOSPORIN 150MG OD R/T
2. TAB CLOPITAB 75MG R/T OD
3. TAB ATOCOR 40MG R/T OD
4. INJ AMIODARONE 150MG STAT F/B
300MG (2AMP) IN 50ML NS @ 8ML/HR FOR 6HRS F/B
600MG (4AMP) IN 50ML NS @ 2.8ML/HR FOR 18HRS
5. IVF : NS, RL, DNS @ 75ML/HR
6. RT FLUID 200ML MILK WITH PROTEIN POWDER, 50ML FREE WATER 1ST HRLY
7. I/O CHARTING, MONTIOR VITALS, GRBS MONITORING 6TH HRLY
8. INJ CEFTRIAXONE 1GM IV/BD
9. TAB PAN 40MG OD
10. NEB IPRAVENT 8TH HRLY, BUDECORT 12TH HRLY
SOAP NOTES DAY 2
ICU BED 1
S:
NO FRESH COMPLAINTS.
O-
PATIENT IS DROWSY
No PALLOR, ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS -
TEMPERATURE - 98.2F
PULSE RATE - 71 bpm
BP - 110/80 mmHg
RESPIRATORY RATE - 17 cpm
SPO2 - 98% @ RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : SOFT, NO ORGANOMEGALY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , IRREGULAR SKIPBEATS+
RESPIRATORY SYSTEM : BAE+, LUNGS CLEAR
CENTRAL NERVOUS SYSTEM : PT IS DROWSY
POWER- SPONTANEOUS MOVEMENTS IN LEFT UL &LL
ABSENT MOVEMENTS IN RT UPPER LIMB & DECREASED MOVEMENTS IN RT LOWER LIMBS.
TONE: NORMAL- IN BOTH LEFT UL&LL
RIGHT : UL- HYPOTONIA
LL- HYPERTONIA
A:
CVA, RIGHT HEMIPARESIS, ATS, MULTIPLE INFRACTS ON MRI IMAGING
CARDIAC EMBOLIC STROKE.
P:
1) TAB ECOSPRIN 150MG OD R/T
2) TAB CLOPITAB 75MG RT OD R/T
3)TAB ATOCOR 40MG RT OD
4) IV FLUIDS NS,RL,DNS @ 75ML/HR
5)RT FEEDS - 200ML MILK WITH PROTEIN POWDER 2ND HOURLY
-50ML FREE WATER 1st HOURLY
6) INJ CEFTRIAXONE 1GM IV/BD
7) TAB PAN 40MG OD BBF
8) NEB WITH IPRAVENT 8TH HOURLY
-BUDECORT- 12TH HOURLY.
9) INJ HEPARIN 5000IU TID
10) TAB CARDARONE 100MG TID
SOAP NOTES DAY 3
ICU BED 1
S:
NO FRESH COMPLAINTS.
O-
PATIENT IS CONSCIOUS
No PALLOR, ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS -
TEMPERATURE - 98.2F
PULSE RATE - 95bpm
BP - 130/70mmHg
RESPIRATORY RATE - 17 cpm
SPO2 - 98% @ RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : SOFT, NO ORGANOMEGALY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD
RESPIRATORY SYSTEM : BAE+, LUNGS CLEAR
CENTRAL NERVOUS SYSTEM : PT IS CONSCIOUS
POWER- SPONTANEOUS MOVEMENTS IN LEFT UL &LL
ABSENT MOVEMENTS IN RT UPPER LIMB & DECREASED MOVEMENTS IN RT LOWER LIMBS.
TONE: NORMAL- IN BOTH LEFT UL&LL
RIGHT : UL- HYPOTONIA
LL- HYPERTONIA
REFLEXES : RIGHT LEFT
BICEPS - 2+ 2+
TRICEPS - 2+ 2+
SUPINATOR - 2+ 2+
KNEE - ABSENT ABSENT
ANKLE - ABSENT ABSENT
PLANTAR - MUTE MUTE
INVESTIGATIONS :
Hb-8.5 TLC-9700 PLATELETS-2.83
S.CREATIININE-1.2
S.ELECTROLYTES : Na-137 K-4.1 Cl-98
A:
CVA, RIGHT HEMIPARESIS, ATS, MULTIPLE INFRACTS ON MRI IMAGING
CARDIAC EMBOLIC STROKE.
P:
1) TAB ECOSPRIN 150MG OD R/T
2)TAB ATOCOR 40MG RT OD
3) IV FLUIDS NS,RL,DNS @ 75ML/HR
4)RT FEEDS - 200ML MILK WITH PROTEIN POWDER 2ND HOURLY
-50ML FREE WATER 1st HOURLY
5) INJ CEFTRIAXONE 1GM IV/BD
6) TAB PAN 40MG OD BBF
7) NEB WITH IPRAVENT 8TH HOURLY
-BUDECORT- 12TH HOURLY.
8) INJ HEPARIN 5000IU TID
9) TAB CARDARONE 100MG TID
SOAP NOTES DAY 4
ICU BED 1
S:
NO FRESH COMPLAINTS.
O-
PATIENT IS CONSCIOUS
No PALLOR, ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS -
TEMPERATURE - 98.6F
PULSE RATE - 89bpm
BP - 140/80mmHg
RESPIRATORY RATE - 17 cpm
SPO2 - 98% @ RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : SOFT, NO ORGANOMEGALY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD
RESPIRATORY SYSTEM : BAE+, LUNGS CLEAR
CENTRAL NERVOUS SYSTEM : PT IS CONSCIOUS
POWER- SPONTANEOUS MOVEMENTS IN LEFT UL &LL
ABSENT MOVEMENTS IN RT UPPER LIMB & DECREASED MOVEMENTS IN RT LOWER LIMBS.
TONE: NORMAL- IN BOTH LEFT UL&LL
RIGHT : UL- HYPOTONIA
LL- HYPERTONIA
REFLEXES : RIGHT LEFT
BICEPS - 2+ 2+
TRICEPS - 2+ 2+
SUPINATOR - 2+ 2+
KNEE - ABSENT ABSENT
ANKLE - ABSENT ABSENT
PLANTAR - MUTE MUTE
A:
- MULTIPLE INFARCTS ON MRI IMAGING - LEFT EXTERNAL WATERSHED TERRITORY, CAUDATE AND THALAMUS
- AF WITH FVR
- CARDIOEMBOLIC STROKE
- OSTEOARTHRITIS OF BOTH KNEES (R>L)
P:
1) TAB ECOSPRIN 150MG OD
2)TAB ATOCOR 40MG OD
3) IV FLUIDS NS,RL,DNS @ 75ML/HR
4) INJ CEFTRIAXONE 1GM IV/BD
5) NEB WITH IPRAVENT 8TH HOURLY
-BUDECORT- 12TH HOURLY.
6) INJ HEPARIN 5000IU TID
7) TAB CARDARONE 100MG TID
SOAP NOTES DAY 5
AMC BED 2
26/4/2022
S:
NO FRESH COMPLAINTS.
O-
PATIENT IS CONSCIOUS
No PALLOR, ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS -
TEMPERATURE - 98.6F
PULSE RATE - 80bpm
BP - 120/70mmHg
RESPIRATORY RATE - 17 cpm
SPO2 - 98% @ RA
INVESTIGATIONS :
PT - 16SEC
APTT - 33SEC
INR - 1.11
SERUM UREA - 40
SERUM CREATININE - 1.1
SYSTEMIC EXAMINATION -
PER ABDOMEN : SOFT, NO ORGANOMEGALY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD
RESPIRATORY SYSTEM : BAE+, LUNGS CLEAR
CENTRAL NERVOUS SYSTEM : PT IS CONSCIOUS
POWER- SPONTANEOUS MOVEMENTS IN LEFT UL &LL
ABSENT MOVEMENTS IN RT UPPER LIMB & DECREASED MOVEMENTS IN RT LOWER LIMBS.
TONE: NORMAL- IN BOTH LEFT UL&LL
RIGHT : UL- HYPOTONIA
LL- HYPERTONIA
REFLEXES : RIGHT LEFT
BICEPS - 2+ 2+
TRICEPS - 2+ 2+
SUPINATOR - 2+ 2+
KNEE - ABSENT ABSENT
ANKLE - ABSENT ABSENT
PLANTAR - MUTE MUTE
A:
- MULTIPLE INFARCTS ON MRI IMAGING - LEFT EXTERNAL WATERSHED TERRITORY, CAUDATE AND THALAMUS
- AF WITH FVR
- CARDIOEMBOLIC STROKE
- OSTEOARTHRITIS OF BOTH KNEES (R>L)
P:
1) TAB ECOSPRIN 150MG OD
2)TAB ATOCOR 40MG OD
3) INJ CEFTRIAXONE 1GM IV/BD
4) NEB WITH IPRAVENT 8TH HOURLY
-BUDECORT- 12TH HOURLY.
5) INJ HEPARIN 5000IU TID
6) TAB CARDARONE 100MG TID
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