A 58 year old male with headache

 58 year old male came with 

Chief complaints:

C/O HEADACHE FRONTAL REGION

H/O LOSS OF SPEECH AND LOSS OF CONSCIOUSNESS FOR 1 HOUR IN THE AFTERNOON AT

11:00AM

C/O COUGHING OUT BLACK COLOURED SPUTUM SINCE EVENING (9:30PM) > E episodes

C/O SWAYING TO RIGHT SIDE SINCE AFTERNOON

C/O HICCUPS SINCE NIGHT (9:30PM)

C/O DIFFICULTY IN SWALLOWING AND HOARSENESS OF VOICE SINCE AFTERNOON


HISTORY OF PRESENTING ILLNESS:

PT WAS APPARENTLY ASYMPTOMATIC TILL TODAY AFTERNOON THEN HE DEVELOPED HEADACHE WHICH WAS FOLIO ONLATEY LOSS OF SPEECH AND FOLLOWED BY LOSS LA CONSCIOUSNESS FOR ONE HOUR. FROM EVENING PATIENT STARTED COUGHING BLACK COLOURED SPUTUM (47 EPISODES).


PAST HISTORY:


K/C/O HTN SINCE 2-3 YEARS ON REGULAR MEDICATION ( T. TELMISARTAN 40MG +

T.CLINIDIPINE 10MG)

K/CIO DM-II SINCE 2-3 YEARS ON IRREGULAR MEDICATION

ADDICTIONS-

ALCHOHOL SINCE 30 YEARS

SMOKING SINCE 30 YEARS

O/E-

PT IS CIC/C

VITALS-BP-210/140 MMHG

PR-116BPM

RR-22CPM

TEMP-101.1F

SP02-94%AT RA

GRBS-197MG/DL

PALLOR-RESENT

ICTERUS- ABSENT

CYANOSIS- ABSENT

CLUBBING- ABSENT

LYMPHADENOPATHY- ABSENT

OEDEMA- ABSENT

CVS-S1S2+, NO MURMURS

RS-BRAE+, WHEEZE PRESENT, CREPTS PRESENT IN RIGHT INFRACLAVICULAR AREA 

PA- SOFT, NON TENDER, BOWEL SOUNDS HEARD 

CNS-

CONSCIOUSNESS- CONSCIOUS 

SPEECH- SLURRED 

CRANIAL NERVES- NAD

SENSORY SYSTEM-

PUPILS:      RT         LT

                  NSRL    NSRL

FACE

                     RT        LT

PAIN           LOST   SPARED

TEMP         LOST   SPARED


UPPER LIMB


                    RT             LT

PAIN          SPARED    LOST

TEMP        SPARED    LOST


LOWER LIMB


                   RT             LT

PAIN          SPARED    LOST

TEMP        SPARED    LOST


BODY

      

                   RT              LT

PAIN          SPARED    LOST

TEMP        SPARED    LOST

 

MOTOR SYSTEM 


POWER

                  RT              LT

U/L           4/5               4/5

L/L            4/5                4/5


TONE

                 RT              LT

U/L          4/5               4/5

L/L          4/5                4/5



GCS- E4V5M6


RHOMBERGS SIGN- POSITIVE


GAIT- ATAXIC


DEATH SUMMARY-


A 55 YEAR OPD MALE CAME TO THE CASUALTY WITH C/O HEADACHE FRONTAL REGION WHICH WAS FOLLOWED BY LOSS OF CONSCIOUSNESS FOR ONE HOUR IN THE AFTERNOON AND WITH C/O COUGHING OUT DARK COLOURED SPUTUM SINCE EVENING (ONLY EPISODES POST RYLES INSERTION) . ON PRESENTATION PATIENT VITALS WERE BP - 210/140 mm hg , TEMP - 101.1F , SPO2 - 94% ON RA , RR - 22CPM , GRBS - 197mg/dl , GCS - 15/15

ON REGULAR EXAMINATION AND INVESTIGATIONS MRI BRAIN DONE OUTSIDE WAS SHOWING ACUTE INFRACT IN RIGHT SIDE OF MEDULLA AND MULTIPLE MICRO HAEMORRHAGES IN B/L CEREBRAL HEMISPHERES AND B/L THALAMUS, AND 2D ECHO SHOWING GLOBAL HYPOKINESIA . IN VIEW OF LOW GCS SECONDARY TO PREVENT THE RISK OF ASPIRATION PATIENT WAS ELECTIVELY INTUBATED IN TRADITIONAL SEQUENCE INTUBATION AND PATIENT WAS KEPT ON VENTILATORY SUPPORT AT 1PM AROUND 10:50PM PATIENT HAD SUDDEN BRADYCARDIA , BP WAS NOT RECORDABLE AND ABSENT CENTRAL AND PERIPHERAL PULSES , CPR WAS INTIATED . AFTER 30MINS OF CPR PATIENT COULD NOT BE REVIVED AND DECLARED DEAD , ECG SHOWING NO ELECTRICAL ACTIVITY AT 11:21PM


IMMEDIATE CAUSE OF DEATH-

CVA WITH ACUTE ISCHAEMIC STROKE INVOLVING RIGHT SIDE MEDULLA


ANTECEDENT CAUSE-

CVA WITH ACUTE ISCHAEMIC STROKE WITH ACUTE INFARCT IN THE RIGHT SIDE OF MEDULLA WITH MULTIPLE MICRO HEMORRHAGES IN B/L CEREBRAL HEMISPHERS AND THALAMUS AND WITH B/L RENAL CALCULI AND K/C/O DM AND HTN WITH HEART FAILURE WITH MIDRANGE EJECTION FRACTION

K/C/O HTN AND DM-II SINCE 32-3 YEARS



2D ECHO (7/12/22)-

CONCENTRIC LVH (1.4CMS)

GLOBAL HYPOKINESIA

MODERATE MR/AR, TRIVIAL TR  

SCLEROTIC, THICKENED AV  

EF=45% RSVP=35MMHG 

MODERATE LV DYSFUNCTION 

DIASTOLIC DYSFUNCTION, NO PE 

IVC SIZE (0.9CMS) COLLAPSING DILATED LA/LV/AORTA


 USG REPORT-

B/L GRADE I RPD 

B/L TINY RENAL CALICULI

SIMPLE RENAL CORTICAL CYST IN RIGHT KIDNEY



TREATMENT:



  1. INJ.MANNITOL 100ML IV/TID
  2. NJ.ZOFER 4MG IV/SOS
  3. INJ.PAN 40MG IV/OD
  4. INJ.NEOMOL IV/SOS IF TEMP >101F
  5. MONITOR VITAL 
  6. NJ.PIPTAZ 4.5GM IVISTAT
  7. NEBULIZATION WITH DUOLIN 6TH HOURLY BUDECORT 12TH HOURLY 
  8. FREQUENT SUCTIONING (every  hrly)
  9. INJ.MIDAZOLAM 2ML/STAT/
  10. INJ.SUCCINYLCHOLINE 2ML/STAT/IV
  11. INJ.GLYCOPYRROLATE 2ML /IV/STAT
  12. IVF NS/RL @50ML/HR
  13. TAB.ECOSPIRIN-AV (75/20) RT/H/S AT 9PM
  14. INJ.OPTINEURON 1 AMP IN 100ML NS IV/OD OVER 30 MIN
  15. INJ.HYDROCORT 100MG/IV//BD
  16. RT FEEDS- 100ML MILK 4TH HOURLY 100ML WATER 2ND HOURLY
  17. STRICT I/O MONITORING 

Comments

Post a Comment

Popular posts from this blog

MEDICINE BLENDED ASSIGNMENT ( MAY)

May 30,   2021 G.Sahithi Reddy medicine Assignment MEDICINE BLENDED ASSIGNMENT May 24,2021 I have been given the following cases to solve in an attempt to understand the topic of 'patient clinical data analysis 'to develop my competency in reading and comprehending clinical data including history ,clinical findings, investigation and diagnosis and come up with the treatment plan.  This is the link of questions asked regarding the cases: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Below are my answers to the medicine assignment based on my comprehension of the cases Pulmonology https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html Question number-1 1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? Evolution of symptomology: 20 yrs...
Read more

40 YEAR OLD WITH GIDDINESS

Image
  40 year old with chief complaints of  GIDDINESS SINCE 3 DAYS LOOSE STOOLS SINCE 3 DAYS YELLOWISH DISCOLOURATION OF SKIN SINCE 2DAYS HISTORY OF PRESENTING ILLNESS : Patients was apparently asymptomatic back then he developed blebs on skin of the palm and thigh which was itchy and slowly progressed through out all the body over 2 months   No treatment was taken for the same   Lesions are non oozing, initially med which then turned dark and left as pigmented seat on the skin. later 3 days back patient developed loose stools and vomiting after using herbal medications for the lesions Patient skipped 3 days taking insulin   LOOSE STOOLS - water consistency , 20episodes/day , sticky , foul smelling not A/W food intake  VOMITINGS - whitish food , non projectile , not blood tinged  YELLOWISH DISCOLOURATION -  eyes and skin since morning with itching Patient developed ulceration @ Rt foot and had amputation of toe PAST HISTORY    K/c/...
Read more

FINAL PRACTICAL EXAMINATION - SHORT CASE

Image
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-centred online learning portfolio and your valuable comments on comment box is welcome. I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  G.Sahithi Reddy Hall ticket no - 1701006043  A 71 year old male patient came to opd with     CHIEF COMPLAINTS OF  Breathlessness and  cough since 20 days HISTORY OF PRESENTING ILLN...
Read more