65 year old male with complaints of slurring of speech and inability to swallow since 4 days

*This E-log was created under the guidance of Dr. Chitra Ma'am 

CHIEF COMPLAINT - 

A 65-YEAR-OLD MALE PRESENTED WITH CHIEF COMPLAINTS OF  SLURRING OF SPEECH AND INABILITY TO SWALLOW FOR THE PAST  4 DAYS.


HISTORY  OF PRESENTING ILLNESS 
 
The patient was apparently asymptomatic 

20 months ago he was admitted because of?TIA

The patient's family describes it with a deviation of mouth (they are not sure about which side) and weakness of limbs.
 
1 year back the patient had a history of cerebrovascular accident which he recovered in 1 week where 
 He was admitted to a hospital for 1 week during which he was diagnosed with  Active Pulmonary Koch's, for which he was on ATT for 6 months. His medical records with respect to the cause of admission are not available.
 
4 days ago, he developed generalized weakness and it worsened the present condition.  
The patients family added that he was finding it difficult to walk

On the day of admission, he came with complaints of slurring of speech, drooling of saliva on the right side, and inability to swallow liquid /solid food for the last 4 days, Deviation of tongue present.

HISTORY OF PAST ILLNESS 

Known case of 
  • Pulmonary KOCH's
  • h/o CVA
 
DRUG HISTORY 

  • ATT for 6 months 

PERSONAL HISTORY 
  • he consumes alcohol 90 ml 3 times a week 
  • has a history of 30 beedis a day since the last 30 years 
  • He has a Mixed diet, adequate sleep
  • Normal bowel movements

FAMILY HISTORY   
  • no relevant family history 

GENERAL EXAMINATION 
  • patient is conscious 
  • slurred speech 
  • moderately built 
  • moderately nourished 
  • absence of pallor, pedal edema, lymphadenopathy, and icterus 

VITALS 
  1. BP- 140/90 
  2. Pulse rate - 80 Beats per minute 
  3. Respiratory rate - 18 cycles per minute 
  4. SPO2 - 96 percent 

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM EXAMINATION 
  • s1, s2 heard 
  • no murmurs or thrills 

RESPIRATORY SYSTEM EXAMINATION 
  • normal vesicular sounds heard 
  • bronchial arterial embolization present 

EXAMINATION OF THE ABDOMEN 
  • soft, non-tender 
  • bowel sounds heard 

CENTRAL NERVOUS SYSTEM EXAMINATION 
  • the patient has dysarthria 
  • he has a deviation of the mouth to the right side 
  • inability to swallow
  • the tone is increased bilaterally in both upper and lower limbs 
  • Fasciculations present 
REFLEXES - 
                            RIGHT                     LEFT 
biceps                       2+                            2+
triceps                      2+                            2+
supinator                  2+                            2+
knee jerk                  -                                +
abdominal                +                              +
plantar                     increased                 increased 




INVESTIGATIONS
  1. MRI brain plain 




  3.  ECG 




  4. Color doppler 2 D ECHO 




  6. CBP, CUE, RFT, LFT, HbA1c, Lipid Profile 

TREATMENT 
DAY 1 
  1. RT feeds with 100 ml Milk 2nd hourly and 100ml water hourly 
  2. INJ PAN 40mg IV /OD
  3. INJ OPTINEURON 1AMP IN 100 ml NS/IV OVER 30 MINUTES 
  4. PHYSIOTHERAPY OF LEFT UPPER LIMB AND FACE 
  5. TAB. CLOPIDOGREL 75 MG RT/OD
  6. TAB. ASPIRIN 150MG RT/OD 
  7. TABATORVAS 40 MG RT /OD
  8. INJ MANNITOL 100 ML 1V

DAY 2 
  1. RT feeds with 100 ml Milk 2nd hourly and 100ml water hourly
  2. INJ PAN 40mg IV /OD
  3. INJ OPTINEURON 1AMP IN 100 ml NS/IV OVER 30 MINUTES
  4. PHYSIOTHERAPY OF LEFT UPPER LIMB AND FACE
  5. TAB. CLOPIDOGREL 75 MG RT/OD
  6. TAB. ASPIRIN 150MG RT/OD
  7. TAB.ATORVAS 40 MG RT /OD
  8. INJ MANNITOL 100 ML 1V

DAY3 
  1. RT feeds with 100 ml Milk 2nd hourly and 100ml water hourly
  2. INJ OPTINEURON 1AMP IN 100 ml NS/IV OVER 30 MINUTES
  3. PHYSIOTHERAPY OF LEFT UPPER LIMB AND FACE
  4. TAB. CLOPIDOGREL 75 MG RT/OD
  5. TAB. ASPIRIN 150MG RT/OD
  6. TAB.ATORVAS 40 MG RT /OD
  7. INJ MANNITOL 100 ML 1V
  8. BP MONITORING 4TH HOURLY 
DIFFERENTIAL DIAGNOSIS 
  1. ACUTE INFARCT INVOLVING RIGHT TEMPORAL AND PARIETAL LOBES - MCA TERRITORY 
  2. OLD INFARCT involving inferior aspect of the left cerebellar hemisphere 
  3. OLD lacunar infarct in the left thalamus 

DISCHARGE SUMMARY 

Name of the Treating faculty 
DR. MADHUMITHA (INTERN)
DR.CHITRA(INTERN)
DR.DIVYA MAHAPATRA (INTERN)
DR.SWAROOPA (INTERN )
DR.SUBHASHINI(INTERN)
DR.DURGA KRISHNA (PG FIRST YEAR ) 
DR. AJITH (PG SECOND YEAR )
DR.HAREEN (SENIOR RESIDENT) 
DR. RAKESH BISWAS (HEAD OF DEPARTMENT, GENERAL MEDICINE ) 


DIAGNOSIS 

LEFT-SIDED CVA WITH ACUTE INFARCT IN MCA TERRITORY INVOLVING RIGHT TEMPORAL AND PARIETAL LOBE 
WITH KNOWN HISTORY OF PULMONARY KOCHS 1.5 YEARS BACK 
WITH KNOWN COMPLAINTS OF CVA 1 YEAR BACK AND A HISTORY OF HTN 1 YEAR 


CASE HISTORY AND CLINICAL FINDINGS
65Y M CAME TO THE HOSPITAL WITH C/O THE SLURRING OF SPEECH, INABILITY TO SWALLOW LIQUIDS AND SOLIDS SINCE FOUR DAYS THERE WAS ALSO C/O DEVIATION OF MOUTH TO RIGHT SIDE AND INABILITY TO WALK SINCE 4 DAYS. 

HE HAS A H/O CVA 1 YEAR BACK WHICH RESOLVED IN 1 WEEK DURING WHICH HE WAS DIAGNOSED WITH ACTIVE PULMONARY KOCHS FOR WHICH HE TOOK 6 MONTHS, AS MENTIONED BY HIS ATTENDANTS 

THE PATIENT WAS UNABLE TO WALK WITHOUT SUPPORT AND WAS FROTH SPILLAGE FROM THE RIGHT SIDE OF THE MOUTH 
ALCOHOL CONSUMPTION 90 ML 3 TIMES A WEEK
30 BEEDIS SINCE THE LST 30 YEARS 

GENERAL EXAMINATION - PATIENT IS CONSCIOUS WITH SLURRED SPEECH, MODERATELY BUILT, AND MODERATELY NOURISHED. NO PALLOR ICTERUS, CYANOSIS, LYMPHADENOPATHY, EDEMA 

BP-110/70MMHG 
PR - 80 BPM
RR- 18 CPM
SPO2- 96 PERCENT 
RESPIRATORY SYSTEM - NVBS HEARD, BAE PRESENT 
CVS- S1, S2 HEARD, NO MURMURS OR THRILLS 
CNS -
PATIENT HAS DYSARTHRIA 
DEVIATION OF MOUTH TO THE RIGHT SIDE, INABILITY TO SWALLOW 
TONE IS INCREASED BILATERALLY IN UPPER AND LOWER LIMBS 
REFLEXES IN RT LT
B2+2+
T2+2+
S2+2+
K-+
A++
P B/L INCREASED 
FASCICULATIONS PRESENT 

INVESTIGATIONS - 
  1. ACUTE INFARCT INVOLVING RIGHT TEMPORAL AND PARIETAL LOBES MCA TERRITORY 
  2. OLD INFARCT INVOLVING INFERIOR ASPECT OF LEFT CEREBELLAR HEMISPHERE 
  3. OLD LACUNAR INFARCT IN LEFT THALAMUS 
TREATMENT GIVEN 
THIS IS A CASE OF A 65-YEAR-OLD MALE WITH ACUTE ISCHEMIC STROKE IN THE MCA TERRITORY INVOLVING THE RIGHT TEMPORAL AND PARIETAL LOBE 
THE PATIENT WAS ADMITTED AND RYLES TUBE WAS INSERTED FOR FEEDING AND TAB ASPIRIN, CLOPIDOGREL, AND ATORVASTATIN WERE ADDED AS SECONDARY THROMBOEMBOLIC PROPHYLAXIS. THE CONDITION OF THE PATIENT AND RECOVERY WAS CLEARLY EXPLAINED TO THE ATTENDEES AND ADVICE FOR DISCHARGE AND ASKED TO CONTINUE THE SAME TREATMENT AT HOME. 


TREATMENT 
DAY 1 
  1. RT feeds with 100 ml Milk 2nd hourly and 100ml water hourly 
  2. INJ PAN 40mg IV /OD
  3. INJ OPTINEURON 1AMP IN 100 ml NS/IV OVER 30 MINUTES 
  4. PHYSIOTHERAPY OF LEFT UPPER LIMB AND FACE 
  5. TAB. CLOPIDOGREL 75 MG RT/OD
  6. TAB. ASPIRIN 150MG RT/OD 
  7. TABATORVAS 40 MG RT /OD
  8. INJ MANNITOL 100 ML 1V

DAY 2 
  1. RT feeds with 100 ml Milk 2nd hourly and 100ml water hourly
  2. INJ PAN 40mg IV /OD
  3. INJ OPTINEURON 1AMP IN 100 ml NS/IV OVER 30 MINUTES
  4. PHYSIOTHERAPY OF LEFT UPPER LIMB AND FACE
  5. TAB. CLOPIDOGREL 75 MG RT/OD
  6. TAB. ASPIRIN 150MG RT/OD
  7. TAB.ATORVAS 40 MG RT /OD
  8. INJ MANNITOL 100 ML 1V

DAY3 
  1. RT feeds with 100 ml Milk 2nd hourly and 100ml water hourly
  2. INJ OPTINEURON 1AMP IN 100 ml NS/IV OVER 30 MINUTES
  3. PHYSIOTHERAPY OF LEFT UPPER LIMB AND FACE
  4. TAB. CLOPIDOGREL 75 MG RT/OD
  5. TAB. ASPIRIN 150MG RT/OD
  6. TAB.ATORVAS 40 MG RT /OD
  7. INJ MANNITOL 100 ML 1V
  8. BP MONITORING 4TH HOURLY 

ADVICE AT DISCHARGE 

  1. TAB ASPIRIN 150 MG/RT/OD AT 2 P.M.
  2. TAB CLOPIDOGREL RT/OD AT 9 P.M.
  3. TAB ATORVAS 40 MG /RT/OD AT 9 PM 
  4. TAB. INCOVIT RT/OD 
  5. PHYSIOTHERAPY OF LEFT UPPER LIMB 





Comments

Post a Comment

Popular Posts