70 year old female with acute ischemic stroke(left MCA territory),? Cardioembolic stroke(heart failure with preserved ejection fraction with RBBB)
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 is welcome.
Here is a case i have seen:
A 70 year old female came with
c/o inability to speak since morning around 7:30 am
No h/o weakness of upper limb and lower limb
No h/o deviation of mouth
No h/o giddiness/syncopal attack
No h/o fall/loss of consciousness/epilepsy
History of present illness:
Patient was apparently asymptomatic 1-2 hrs back then around at 7am patient son went to wake him up which was his usual time where he observed she was unable to speak but she was able to move her both upperlimbs and lowerlimbs on bed and there was no deviation of mouth.
She was not responding to commands but her eyes were open .
She was rushed to local rmp and was told low bp there for which she was given salt water and was referred to kamineni
Then she presented to our hospital only with inability to speak
She was apparently normal previously where she did her daily routine
Yesterday she did her routine activities like watched tv,ate dinner and went to bed around 8pm
There were no similar episodes in the past
Not k/c/o TB,DM,HTN,ASTHMA,CAD,EPILEPSY AND THYROID DISORDER
K/c/o hypotension based on attender words
Personal h/o :
Married
Patient have mixed diet
Loss of appetite
Bowel bladder movements normal
No addictions
O/e
Patient is c/c/c
no pallor, icterus, cynosis, clubbing, lymphAdenopathy,pedal edema
Afebrile on touch
PR - 72/min
BP - 150/100 mmHg
CVS S1S2 +
RS BAE +
P/A soft non tender
CNS:
HMF
Aphasia +
Not Oriented to time place person
CRANIAL NERVES could not be elicited
MOTOR SYSTEM
Power could not be elicited
Tone:
LL Normal Normal
Bulk: inspection Normal Normal
palpation. Normal NormalReflexes:B T S K A. P
Right: 2+ 2+ 2+ 2+ 0 extenLeft: 2+ 2+ 2+ 2+ 0 exten
SENSORY could not be elicited
CEREBELLAR SIGNS could not be elicitedInvestigations:
hb:12.5mg/dl
tlc:10,000
Plt:2.08
pcv:36.3
Mcv:81.6
Mch:28.8
Mchc:35.3
troponin I:negative
CT Brain:
Hypodensity of 22-26 HU with loss of grey white matter differentiation involving left fronto parietal and temporal lobes and left basal ganglia(acute infarct of left MCA territory)
No evidence of hemorrhage
no evidence of midline shift/mass effect
2d echo:
Chest x ray:
Treatment:
Ryles tube insertion
Foley's catheterisation
Rt feeds 100ml milk+protein 4th hrly
50ml free water 4th hrly
Tab ecosporin gold/rt/hs
Inj optineuron 1amp in 100ml ns/iv/od
Bp charting 2nd hrly
Grbs charting 6th hrly
Day 2:
No fresh complaints
O/e: pt drowsy but arousable
GCS-E2V1M5
Afebrile
PR-75bpm
Bp-120/70mmhg
Input-700/1200ml
Grbs-122mg/dl
Cvs-s1,s2+
Rs-BAE+
P/A-soft,non tender
CNS:
Aphasia+
HMF: speech -
Not Oriented to time/place/person
Pupils b/l reacting to light +
Memory: immediate -
Recent -
Remote -
Cranial nerves:could not be elicited
Motor system:
Power could not be elicited
Tone:
UL Normal Normal
LL Normal Normal
Bulk: inspection Normal Normal
palpation. Normal Normal
Reflexes:
B T S K A P
Right: - - - - - Exten
Left: + - - - - exten
Sensory system: could not be elicited
Cerebellar signs:could not be elicitedRt feeds 100ml milk+protein 4th hrly
50ml free water 4th hrly
Tab ecosporin gold/rt/hs
Inj optineuron 1amp in 100ml ns/iv/od
Bp charting 8th hrly
Grbs charting 6th hrly
O/e: pt drowsy but arousable
GCS-E2V1M5
Afebrile to touch
PR-82bpm
Bp-130/70mmhg
Input-950/900ml
Grbs-125mg/dl
Cvs-s1,s2+
Rs-BAE+
P/A-soft,non tender
CNS:
HMF: Aphasia+
Not Oriented to time/place/person
Pupils b/l reacting to light +
Memory: immediate -
Recent -
Remote -
Cranial nerves:could not be elicited
Motor system:
Power could not be elicited
Tone:
UL Normal Normal
LL Normal Normal
Bulk: inspection Normal Normal
palpation. Normal Normal
Reflexes:
B T S K A P
Right: 0 0 0 0 0 Exten
Left: + + 0 0 0 exten
Sensory system: could not be elicited
Rt feeds 100ml milk+protein 4th hrly
50ml free water 4th hrly
Tab ecosporin gold/rt/hs
Inj optineuron 1amp in 100ml ns/iv/od
1 unit ns@50ml/hr (slow infusion)
Bp charting 8th hrly
Grbs charting 6th hrly
O/e: pt drowsy but arousable
GCS-E2V1M5
Afebrile to touch
PR-72bpm
Bp-130/70mmhg
Input-1400/1000ml
Grbs-110mg/dl
Cvs-s1,s2+
Rs-BAE+
P/A-soft,non tender
CNS:
HMF: Aphasia+
Not Oriented to time/place/person
Pupils b/l reacting to light +
Memory: immediate -
Recent -
Remote -
Cranial nerves:could not be elicited
Motor system:
Power could not be elicited
Tone:
UL Normal Normal
LL Normal Normal
Bulk: inspection Normal Normal
palpation. Normal Normal
Reflexes:
B T S K A P
Right: 3+ 0 0 0 0 Exten
Left: 0 3+ 0 0 0 exten
Sensory system: could not be elicited
Tab ecosporin gold/rt/hs
Inj optineuron 1amp in 100ml ns/iv/od
1 unit ns@50ml/hr (slow infusion)
Bp charting 8th hrly
Grbs charting 6th hrly
Day 5:
O/e: pt drowsy but arousable
GCS-E2V1M5
Afebrile to touch
PR-72bpm
Bp-140/70mmhg
I/o:800/1200ml
Grbs-108mg/dl
Cvs-s1,s2+
Rs-BAE+
P/A-soft,non tender
CNS:
HMF: Aphasia+
Not Oriented to time/place/person
Pupils b/l reacting to light +
Memory: immediate -
Recent -
Remote -
Cranial nerves:could not be elicited
Motor system:
Power could not be elicited
Tone:
UL Normal Normal
LL Normal Normal
Bulk: inspection Normal Normal
palpation. Normal Normal
Reflexes:
B T S K A P
Right: 1+ 0 0 0 0 Exten
Left: 2+ 1+ 0 2+ 0 exten
Sensory system: could not be elicited
Tab ecosporin gold/rt/hs
Inj optineuron 1amp in 100ml ns/iv/od
1 unit ns@50ml/hr (slow infusion)
Bp charting 8th hrly
Grbs charting 6th hrly
Physiotherapy
Day 6:
O/e: pt drowsy but arousable
GCS-E4V1M5
Afebrile to touch
PR-70bpm
Bp-120/80mmhg
I/o:1500/1800ml
Grbs-102mg/dl
Cvs-s1,s2+
Rs-BAE+
P/A-soft,non tender
CNS:
HMF: Aphasia+
Not Oriented to time/place/person
Pupils b/l reacting to light +
Memory: immediate -
Recent -
Remote -
Cranial nerves:could not be elicited
Motor system:
Power could not be elicited
Tone:
UL Normal Normal
LL Normal Normal
Bulk: inspection Normal Normal
palpation. Normal Normal
Reflexes:
B T S K A P
Right: 1+ 0 0 0 0 Exten
Left: 2+ 0 0 0 0 exten
Sensory system: could not be elicited
Tab ecosporin gold/rt/hs
Inj optineuron 1amp in 100ml ns/iv/od
1 unit ns@50ml/hr (slow infusion)
Bp charting 8th hrly
Grbs charting 6th hrly
Physiotherapy
Comments
Post a Comment