case 35 : 80 YEAR OLD MALE WITH ALTERED SENSORIUM

 

80 YEAR OLD MALE WITH ALTERED SENSORIUM

May 11, 2022
21st April, 2022
thanks Dr. amatul 

ICU ADMISSION

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"

80 year old male farmer by occupation residing in miryalguda came with chief complaints of
- 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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