55 YEAR OLD WITH ALTERED SENSORIUM UNDER EVALUATION









 ICU Last bed new admission 

55 year old male patient came to the casuality with complaints of altered sensorium since 1 day 


Patient was apparently asymptomatic 6 years back when he had chest pain, radiating to left arm and was taken to hospital. 

ECG showing MI pattern and had CABG , and was on regular medication 


C/O altered sensorium since 1 day.

C/O headache prior to it, radiating to neck and took 2 tablets of anti hypertensive ( tab. ? Unknown )


No c/o chest pain 

No involuntary movements of UL/LL

No palpitations

No h/o Shortness of breath.

HISTORY BEFORE COMING TO KIMS:


One day prior was alright till morning after breakfast he complained of giddiness and headache and took 2 antihypertensives, and slept,he called for attender and fell from the bed, and they noticed he couldn't get up or walk without support dragging his right leg, and not talking properly, he was taken to miriyalguda hospital on bike,where CT brain was done which was normal, he was given IV fluids and stayed there till yesterday morning, as his general condition wasn't improving he was referred here.


PAST HISTORY:

Patient is a k/c/o HTN since 4 years.

Not a k/c/o DM/TB/epilepsy 


Alcoholic + occasionally

Non-smoker.


VITALS ON ADMISSION:

Temp- 96.5

PR- 70 bpm

BP- 170/90 mmhg

RR-18 cpm

Spo2- 98% at room air

GRBS- 115 mg/dl

 

ON EXAMINATION :






CVS- S1 S2 + No murmurs 



RS- NVBS+ No crepts

P/A- soft, non tender.

CNS:

Level of consciousness- drowsy 

Speech- slurred 

Deviation of mouth to the left

No signs of meningeal irritation

Motor system:

                Rt              Lt

Tone

       UL   Decreased     N

       LL.        N             N

      

Power

       UL.       4/5.     4/5 (probably 5/5)

       LL.        4/5.     4/5 (probably 5/5)


Reflexes

             B.       -         2+

             T.        -        2+

             S.        -        2+

             A.        2+.    2+

             K.        2+.    2+

             P.      WD    WD


PROVISIONAL DIAGNOSIS:

Right Hemiparesis with altered sensorium secondary to ? CVA

C/o giddiness with CVA involving ?PCA Territory

S/p CABG ( 6 years back) with k/c/o HTN since 4 years 

INVESTIGATIONS:


ECG:



CHEST X-RAY:



2D ECHO:

S/p CABG 

Concentric LVH +. No RWMA

Trivial TR+/AR+. No MR

Sclerotic AV. No AS/MS

EF- 58%. RVSP- 35 mmhg

Good LV Systolic function. Diastolic dysfunction +

No PAH/ PE

IVC size 0.8 cm ( collapsed)


MRI BRAIN:



Impression:

Acute infarct in both sides of pons and left side of midbrain.

Dilated perioptic CSF spaces and empty 

sella- To rule out raised ICT


DIAGNOSIS:


1. Acute infarct in both sides of pons and left side of midbrain 

2. Post CABG 6 years back 

3. K/c/o HTN since 4 years



COURSE IN THE HOSPITAL:

DAY 1:

IVF NS/RL @ 75 ml /hr

Inj Optinueron in 1 DNS IV/OD

Inj. Ceftrioxone 1g /IV/BD

Inj. Pantop 40 mg IV/OD

Monitor vitals 2 hourly 

Input/ output charting.


DAY 2:


Inj Monocef 1 g IV/BD

Inj. Pantop 40 mg IV/OD

Inj Optinueron in 1 DNS IV/OD

Tab. Ecospirin- AV PO/OS

Tab. Clopidogril 75 mg PO/ H/S

Monitor vitals 2 hourly 

Input/ output charting



 

DAY 3:


S:

Pts sensorium has improved.

He is conscious and responding to commands 

Slurred speech +

C/o giddiness 


O: 

PR- 71 bpm, regular 

BP- 150 / 90 mmhg

Spo2- 99% at RA

Temp- 98.6F

CNS:

Sensorium improved

Pupils b/l reacting to light 

Conjunctival reflex +

Corneal reflex +

                  Rt            Lt

Tone

       UL   Decreased  N

       LL.        N             N

      

Power

       UL.       2/5.      5/5 

       LL.        2/5.      5/5


Reflexes

             B.       2+.     3+

             T.       3+.     3+

             S.       +        3+ 

             A.       2+.    3+

             K.       +.      2+

             P.        ^.      ^



A: 

1. Acute infarct in both sides of pond and left side of midbrain 

2. Post CABG 6 years back 

3. K/c/o HTN since 4 years 



P:

Head end elevation

monitor vitals 

strict input/output

ryles tube feeding

Inj. Mannitol 100 ml /IV/TID

Tab.Amlong 10 mg /RT/OD

Tab. Pan 40 mg /RT/ BBF

Tab. Ecosprin gold/ RT/ HS

Inj. Optineuron 1 amp in 100 ml/ IV/OD

Physiotherapy of Rt UL and LL


 

DAY 4:


S:

Pts sensorium has improved.

He is conscious and responding to commands 

Slurred speech +

Difficulty in swallowing present.


O: 

PR- 80 bpm, regular 

BP- 160 / 90 mmhg

Spo2- 99% at RA

Temp- 98.4F

CNS:

Sensorium improved

Pupils b/l reacting to light 

Conjunctival reflex +

Corneal reflex +

                  Rt            Lt

Tone

       UL   Decreased  N

       LL.   Decreased N

      

Power

       UL.       2/5.      5/5 

       LL.        2/5.      5/5


Reflexes

             B.       2+.     3+

             T.       3+.     3+

             S.       +        3+ 

             A.       3+.    3+

             K.       +.      2+

             P.        ^.      ^



A: 

1. Acute infarct in both sides of pond and left side of midbrain 

2. Post CABG 6 years back 

3. K/c/o HTN since 4 years 



P:

Head end elevation

monitor vitals 

strict input/output

ryles tube feeding

Inj. Mannitol 100 ml /IV/TID

Inj. Metrogyl 100 ml/IV/BD

Tab.Amlong 5 mg /RT/OD

Tab. Pan 40 mg /RT/ BBF

Tab. Ecosprin gold/ RT/ HS

Inj. Optineuron 1 amp in 100 ml/ IV/OD

Physiotherapy of Rt UL and LL

 

DAY 6


S:

Pts sensorium has improved.

He is conscious and responding to commands 

Slurred speech +


O: 

PR- 79bpm, regular 

BP- 140 /80 mmhg

Spo2- 98% at RA

Temp- 98.4F

GRBS-124 mg/dl

CVS- S1 S2 + No murmurs 

RS- NVBS+ No crepts


CNS:

Sensorium improved

Pupils b/l reacting to light 

Conjunctival reflex +

Corneal reflex +

                  Rt            Lt

Tone

       UL   Decreased  N

       LL.   Decreased N

      

Power

       UL.       3/5.      5/5 

       LL.        3/5.      5/5


Reflexes

             B.       2+.     3+

             T.       3+.     3+

             S.       +        3+ 

             A.       +.       2+

             K.       +.      2+

             P.        ^.      ^



A: 

1. Acute infarct in both sides of pons and left side of midbrain 

2. Post CABG 6 years back 

3. K/c/o HTN since 4 years 



P:

1. Head end elevation

2. RT feeds - 50ml free water 2nd hourly , 100ml milk with 2 scoops of Protein powder 4th hourly

3. Tab ECOSPIRIN GOLD / RT/ H/S

4. Inj OPTINEURON 1 Ampule in 100ml / IV / OD

5.Tab.Amlong 5 mg /RT/OD @8AM

6.Physiotherapy of Rt UL and LL


AMC case , Unit 1

55/ M


 

DAY 7


S:

Pts sensorium has improved.

He is conscious and responding to commands 

Slurred speech +


O: 

PR- 84bpm, regular 

BP- 130 /80 mmhg

Spo2- 98% at RA

Temp- 97.4F

GRBS-103 mg/dl

CVS- S1 S2 + No murmurs 

RS- NVBS+ No crepts

I/O 1500/1400 ml

CNS:

Sensorium improved

Pupils b/l reacting to light 

Conjunctival reflex +

Corneal reflex +

                  Rt            Lt

Tone

       UL   Decreased  N

       LL.   Decreased N

      

Power

       UL.       3/5.      5/5 

       LL.        3/5.      5/5


Reflexes

             B.       2+.     3+

             T.       3+.     3+

             S.       +        3+ 

             A.       +.       2+

             K.       +.      2+

             P.        ^.      ^



A: 

1. Acute infarct in both sides of pons and left side of midbrain 

2. Post CABG 6 years back 

3. K/c/o HTN since 4 years 



P:

HEAD END ELEVATION

Tab ECOSPIRIN GOLD / RT/ H/S

Inj OPTINEURON 1 Ampule in 100ml / IV / OD

Tab.Amlong 5 mg /RT/OD @8AM

Physiotherapy of Rt UL and LL


 

DAY 8


S:

Pts sensorium has improved.

He is conscious and responding to commands 

Slurred speech +


O: 

PR- 84bpm, regular 

BP- 130 /80 mmhg

Spo2- 98% at RA

Temp- 97.4F

GRBS-103 mg/dl

CVS- S1 S2 + No murmurs 

RS- NVBS+ No crepts

I/O 1500/1400 ml

CNS:

Sensorium improved

Pupils b/l reacting to light 

Conjunctival reflex +

Corneal reflex +

                  Rt            Lt

Tone

       UL   Decreased  N

       LL.   Decreased N

      

Power

       UL.       3/5.      5/5 

       LL.        3/5.      5/5


Reflexes

             B.       2+.     3+

             T.       3+.     3+

             S.       +        3+ 

             A.       +.       2+

             K.       +.      2+

             P.        ^.      ^



A: 

1. Acute infarct in both sides of pons and left side of midbrain 

2. Post CABG 6 years back 

3. K/c/o HTN since 4 years 



P:

HEAD END ELEVATION

Tab ECOSPIRIN GOLD / RT/ H/S

Tab.Amlong 5 mg /RT/OD @8AM

Physiotherapy of Rt UL and LL



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