1601006155 LONG CASE

 

1601006155- Long Case


 

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A 64-year-old male patient, who is a Sarpanch by occupation, hailing from Sagar, was brought to the casualty on 27th of March, 2021 with dizziness, vomiting and decreased response since 5hours. 

History of present illness:

•Patient was apparently asymptomatic 5 hours back, then he felt dizzy and with vomitings, decreased responses and His Blood pressure levels were 190/100 mmHg. 

•He had weakness in left upper  and lower limbs, then immediately CT scab was done and it showed meningeal bleed and the patient was immediately admitted.

•After admission patient has decreased urine output and metabolic acidosis. 

•He was started on Hemodialysis, twice weekly.  Last dialysis was done 3days back. 

Past History: 

•He was diagnosed with CKD, 10 years ago, for which he was put under medication and was suggested to start on Hemodialysis, to which the patient didn’t comply with. 

•Patient had PTB, two years ago, and he was under ATT for an year. 

•The patient is not a known case of Hypertension, Diabetes Mellitus, Thyroid abnormalities, asthma, Epilepsy, and CVDs.

Personal History: 

  • Diet- Vegetarian 
  • Appetite- Normal
  • Bowel and bladder movements- Regular 
  • Sleep- adequate
  • Addiction- Alcohol and Smoking since 30 years, stopped 6years back. 
  • No known allergies 

Family History: 

NAD 

GENERAL EXAMINATION 

Patient was with altered consciousness, non coherent and non cooperative.

Moderately built and Moderately nourished 

•Pallor- Absent 

•Icterus-Absent 

•Clubbing- Absent 

•Cyanosis- Absent 

•Koilonychia-absent 

•Lymphedenopathy-Absent 

•Edema- bilateral pedal edema present 


VITALS:

•Temperature- Afebrile 

•Pulse rate- 92bpm, regular rhythm and normal volume

•Respirate rate- 12cpm

•Blood pressure- 130/90 mm of Hg

•SpO2- 97%

•GRBS- 122mg/dl.


SYSTEMIC EXAMINATION  

CENTRAL NERVOUS SYSTEM

•Motor System -               Right              Left 

         -Bulk- inspection    Normal          Normal 

                   Palpation      Normal         Normal 

             Measurements 

                 UpperLimb     28cm             28cm

                 LowerLimb     37cm             37cm 

      -Tone 

              UpperLimb        Normal         Hypotonia 

              LowerLimb       Normal         Hypotonia 

     -Power 

            Upper limb    Spontaneously    Not Moving 

                                     moving    

            Lower limb   Spontaneously     Not Moving 

                                     moving 

 •Reflexes 

       •Biceps               +2                     +2
        •Triceps             +2                     +2
        •Supinator         +2                     +2
        •knee                 +2                     +1
        •Ankle               +1                     0

        •Plantat          flexor               extensor             





 •Sensory System 

          Touch&Pressure        Could not be elicited 

          Thermal Sensation    Could not be elicited 

          Pain                            Present          Present 

          Vibration                   Could not be elicited 

          Proprioception          Could not be elicited 

•Cranial Nerves  

         Could not be elicited 

•Gait 

     Can not be observed due to hemiplegia 

•Meningeal signs

      Kerning’s sign - absent 

      Neck stiffness - absent 

•Cerebral signs 

     Finger-Nose coordination test- could not be elicited 

     Knee- heel coordination test -  could not be elicited 

•Glasgow-Coma Scale 

    Eye Response     - 4

    Verbal Response - 2 

    Motor response   - 4

  GCS score = 10; indicates Moderate Brain Injury

MUSCULOCUTANEOUS SYSTEM 

  -Bed sores 

     At gluteal region - Grade IV

     At heel region     - Grade II   


 CARDIOVASCULAR SYSTEM

    S1, S2 Heard 

    No murmurs 

RESPIRATORY SYSTEM  

    Normal vesicular breath sounds heard 

    No added sounds 

ABDOMINAL EXAMINATION  

    Soft, No tendernerness, central umbilicus 

    No Organomegaly 


INVESTIGATIONS  


   

Provisional Diagnosis:

Left sided hemiplegia secondary to hemorrhagic stroke, with HTN, with CKD on MHD and with grade IV bed sores.


Treatment: 

•Tab. Amlong 10mg -OD


•Inj. Lasix 400mg - BD

•Inj. Clindamycin 600mg -IV/ TID 

•Tab. Nodosis 500mg -OD


•Tab. Shelcal 500mg -OD


•Syrup Lactulose 15ml -TID 

•Inj. Erythropoietin 4000IU SC/ weekly twice 

•Salt and fluid restriction 

•Air/water bed 

•Frequent change of posture - 2nd hourly 

•RT feed - Milk+protein powder and Water 

•Daily bed sore dressing 

•Physiotherapy of left upper and lower limbs






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