D Nikhil Venkata Reddy 1801006038 Roll no 41

79 y/o male with Recurrent CVA and left hemiplegia with Aspiration pneumonia and seizures disorder

- March 16, 2023

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COMPLAINTS AND DURATION

A 79 y/o male was brought to casuality with c/o cough since 20 days , 

fever since 10 days

difficulty in swallowing and h/o Aspiration pneumonia since one month

C/o altered sensorium since 3 days

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 20days back then he developed cough insidious in onset and gradually progressive. PRODUCTIVE but patient is not able to spit it out. 

Difficulty in swallowing.

Series of events as follows

* Patient developed cough and cold on 25th February 2023

* Took treatment for cold on March 1st

* There were increased secretions on  March 3rd but the patient was unable to spit it out

* Admitted in hospital from March 5th to March 10th and cleared secretions through suction.

H/O cough on intake of liquids.

H/O change of voice since 20 days, insidious, hoarse in character and  SLURRING OF SPEECH is present

No H/O difficulty in breathing, breathlessness, hemoptysis. 

Fever since 10 days - High grade. 

O/E Chills and rigors + (38 spikes).

N/H/O Vomiting, Chest pain, Loose stools.

7 YEARS AGO(2016)

He developed head ache at around afternoon 2pm followed by vomtings and left hand itching and weakness.

PATIENT was awake on that night due to left hand weakness and itching

NEXT DAY 

MORNING they took him to hospital 

Patient can lift his hand 

But unable to hold objects

AFTER 3 DAYS

PATIENT became left sided hemiplegia.

MRI REPORT shows 3 INFARCTS

Patient stayed for 40 days in hospital and there was no improvement and discharged.

He took liquids for 3 months because patient is unable to eat solid foods. He then slowing started eating solid foods.

AFTER 1 YEAR (2017)

vomitings 

Fever 

Shivering for 3 days

 

Diagnosed with urinary tract infection 

Took treatment (antibiotics) for 5 days and it was resolved

AFTER 3 YEARS(2020)

Cough for 2 days 

Fever on 2 nd day

Diagnosed with covid

Infected with COVID for 1st time and resolved

After 1 year(2021)

 He was Diagnosed with COVID for 2nd time and resolved 

1 YEARS back (2022)

He got seizures for 5 min and they took him to the hospital.

He got Typhoid fever 2times 

1st time resolved in 7days

2nd time resolved in 9 days

79 Year old male who is a father of 4 children ( 2 sons and 2 daughters) used to run a shop ( kirana shop) for about 18 years.He stopped looking after his shop from 2006 and he was looked after by his sons. 

He was non alcoholic,non smoker.

10 years ago , patient developed lesions on his both foot and went to the doctor and found to have diabetes and started on medication and after 1 year ,with regular check up he was found to be Hypertensive and started on antihypertensive medication.

From 7 years onwards , patient was bedridden with foleys ( changed every 15 days ) and physiotherapy was done by his attenders daily, but there was no such improvement

PAST HISTORY  

Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is on medications I.e tab TELMA AM 40mg andTab zoryl. 

PERSONAL HISTORY 

Appetite - lost

Mixed - Diet

Bowel - Constipated, 

Bladder - Regular 

No known allergies and Addictions. i.e non alcoholic and non smoker

Family History

Not significant 

Treatment history   

 

Tab TELMA AM 40mg po/od since past 10years

Tab zoryl mv , po/od

Tab levipil 500mg since 2 years

Thyronorm 25mcg. Since5 years

GENERAL EXAMINATION 

On examination patient is arousable but not oriented.

Patient is not cooperative mostly. 

-PALLOR: PRESENT

NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS ON ADMISSION 

Pulse Rate -b90 BPM

BP- 140/80MM HG

Respiratory Rate - 22 CPM

SPO2- 98%

GRBS - 183mg/dl

SYSTEMIC EXAMINATION

Respiratory 

Inspection : respiratory movements equal on both sides

Trachea is  central

palpation apical impulse in left 5th intercostal space 

Auscultation : Crepitations on auscultation

Percussion- BAE+

Tachypnea is present 

CNS 

PATIENT is unconscious incoherent uncooperative

HIGHER MENTAL FUNCTIONS- cannot be elecited

Speech 

Behaviour

Memory

Intelligence

Lobar functions

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION

CRANIAL NERVES 

 2nd cranial nerve 

Visual acuity is decreased on left side

3rd 4th 6th pupillary reflex present

 SENSORY SYSTEM- cannot be elicited 

Spinothalamic sensation

Crude touch

Pain  

Temperature

Dorsal column sensation

Fine touch 

Vibration

Propioception

Cortical sensation

Two point discrimination

Tactile localisation

Stereognosis

Graphathesia

MOTOR EXAMINATION

                 

                       Right                          Left

                    UL LL                          UL LL

  BULK    Normal Normal            Reduced                            

 TONE     Normal                      Hypotonia

 POWER     Could not be elicited

SUPERFICIAL REFLEXES

plantar reflex  

Left side babinski sign positive

  DEEP REFLEXES

BICEPS, TRICEPS, SUPINATOR, KNEE ANKLE 

CEREBELLAR EXAMINATION cannot be elicited

  Finger nose test

  Heel knee test 

  Dysdiadochokinesia

  Dysmetria

hypotonia with pendular knee jerk present.

  Intention tremor present.

  Rebound phenomenon .

  Nystagmus

  Titubation

  Speech

  Rhombergs test

SIGNS OF MENINGEAL IRRITATION: absent

GAIT

 patient unable to walk

CVS

AUSCULTATION: S1S2 +,NO MURMURS

P/A

INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS

AUSCULTATION

No bowel sounds heard

bed sores

C/O asymptomatic lesions all over the body since 2 months

H/O application of unknown topical medications used

O/E multiple hyperpigmented Macclesfield present all over the body with scaly lesions over the upper back

•Diffuse xerosispresent

• single ulcer of size 1.5x1.5 cms (approx) over the back.

Diagnosis SENILE XEROSIS + post inflammatory hyperpigmentation.

( +? TROPHIC ULCER )OBSERVATIONS:

• Large area of encephaolomalacia in right occipito -temporo lobes and righ parietal lobes.

• Prominence of sulci and cisterns. 

• Bilateral periventricular hyperintensity.

• Rest of the Cerebral parenchyma shows normal gray/white matter differentiation.

• Basal ganglia and Thalami are normal.

• Brain stem normal.

• Cranio-vertebral and Cervico-medullary junctions are normal.

• Sella, pituitary and parasellar regions are normal. Stalk and hypothalamus are normal. Posterior pituitary bright spot is normal.

• No evidence of abnormal calcifications, vascular anomalies on SWI sequences.

IMPRESSION:

• Large area of encephalomalacia in right occipito-temporo lobes and right parietal lobes - sequelae of old infarct.

• Diffuse cerebral atrophy. Chronic small vessel ischemia.

Note: Poor quality of images due to motion artefacts

CUE 

AFB-TRACE

PUS CELLS -2-4

EPITHELIAL CELLS -2-3

LFT 

INVESTIGATIONS

Anti HCV antibodies rapid - Nonreactive

Blood urea - 30mg/dl

HBA1C- 6.7%

HbsAg rapid - Negative

HIV 1/2 RAPID TEST - NON REACTIVE

TOTAL BILIRUBIN -0.81mg/dl(normal-0 to 1mg/dl)

Direct bilirubin-0.17mg/dl(0 to 0.2mg /dl)

Serum creatinine -0.9 mg/dl (0.8 to 1.3 mg /dl)

ABG

Ph 7.51

PCO2 29.5mmhg

Po2 67.5 mmhg

ELECTROLYTES

Sodium 135meq/l

Potassium 3.5 meq/l

Chloride 98meq/l

Calcium -1.06 mmol/l

PROVISIONAL DIAGNOSIS 

 Recurrent CVA with Hypertension, T2 DM, seizures disorder. 

TREATMENT 

1) TAB ECOSPRIN 150 mg RT/OD

 2) TAB CLOPIDOGREL 75 MG RT/OD 

3) TAB ATORVAS 20 MG RT/OD

4) NEBULISATION - 3% NS                              5)CHEST PHYSIOTHERAPY.

6) RT FEEDS 100 ML WATER 2nd HRLY

                        50 ML Milk 2nd HRLY.

8) TAB. THYRONORM 25MCG RT/OD

9) TAB. LEVIPiL