1601006143 long case

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A 64 year old male patient, sarpanch by occupation hailing from sagar was brought to the causuality on 27-03-2021 with dizziness, vomitings and decrease response since 5 hours 

History of presenting illness:

Patient was apparently asymptomatic 5hours back then he suddenly developed dizziness, vomitings and decreased response and was brought to the hospital immediately and was diagnosed with high blood pressure of 190/100 mm of Hg and weakness of both left upper and lower limbs. 

Then immediately CT scan was done and it showed intracranial bleed and the patient was immediately admitted.

After admission patient had decreased urine output and metabolic acidosis, started on hemodialysis twice weekly. Last dialysis was done 3days back.

Past history:

Patient was diagnosed with CKD 10 years ago and is on medication and was also suggested to start on hemodialysis for which patient didn't comply with.

He had pulmonary tuberculosis 2 years ago and was treated for 1 year.

He is not a know case of Hypertension, Diabetes mellitus, asthma, epilepsy, thyroid abnormalities and Cadiovascular disorders.

 Personal history:

•Apetite- Normal

•Diet- Vegetarian 

•Sleep- Adequate 

•Bowel and Bladder- Regular

•Addictions- Alcohol and smoking since 30 years and stopped 6 years back.

General examination:

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

Moderately built and Moderately nourished 

•Palllor- 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:

☆CNS Examination:

Motor system examination:

▪︎Bulk:                     Right                Left

     Inspection-

       •Upper limb      Normal             Normal

       •Lower limb      Normal             Normal

     Palpation-

       •Upper limb      Normal             Normal 

       •Lower limb      Normal             Normal

     Measurements-

       •Midarm            Normal             Normal 

        circumference 

       •Mid thigh         Normal             Normal 

        circumference 

▪︎Tone: 

        •Upper limb      Normal            Hypotonia

        •Lower limb      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

        •Plantor              flexor               extensor

Sensory system examination:

Could not be elicited 

Cranial Nerves examination:

Could not be elicited

Gait:

Could not be elicited

Meningeal signs:

• Neck stiffness - Absent 

•kerning's sign - Absent 

 

Cerebral sings:

Could not be elicited 

Glasgow scale:

• Eye response - 4

• Verbal response - 2

• Motor response - 4

GSC score= 10, indicates moderate brain injury.

☆Musculocutaneous System Examination:

Bed sores in Gluteal region - Grade 4,

                       Heel - Grade 2.

☆CVS Examination:

No thrills

S1, S2 heard

No murmurs.

☆Repiratory System Examination:

Vesicular breath sounds heard

No added sounds

☆Gastrointestinal System Examination:

Soft abdomen, central umbilicus

No organomegaly

No tenderness

Investigations:

Provisional diagnosis:

Left sided hemiplegia secondary to hemorrhagic stroke, with Hypertension, CKD on MHD, with grade 4 bedsores.

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