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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