ALTERED SENSORIUM SECONDARY TO ACUTE INFARCT IN LEFT MCA TERRITORY (LEFT FRONTAL,TEMPORAL,PARIETAL LOBES) WITH RIGHT HEMIPARESIS GENERALISED TONIC CLONIC SEIZURES ASPIRATION PNEUMONIA HEART FAILURE WITH MID RANGE EJECTION FRACTION(EF=49%) WITH ACUTE PULMONARY EDEMA K/C/O HYPERTENSION SINCE 3 YEARS K/C/O CKD K/C/O HYPOTHYROIDISM SINCE 1.5 YEARS K/C/O COPD

Case History and Clinical Findings

A 85 YEAR OLD MALE PRESENTED TO CASUALTY IN UNRESPONSIVE STATE AT 10 AM

-DIFFICULTY IN WALKING SINCE 3-5 YEARS

HOPI:-PATIENT WAS APPRENTLY ASYMPTOMATIC TILL TODAY MORNING AND THE PATIENT HAD AN HISTORY OF FALL AT HOME FROM CHAIR AT 10 AM AND AFTER THAT PATIENT WAS NOT TALKING SINCE THEN AND NO INVOLUNTARY MOVEMENTS.

FROTHING FROM MOUTH –NEGATIVE

INVOLUNTARY DEFECATION- NEGATIVE ; MICTURITION + ;

DEVIATION OF MOUTH TOWARDS LEFT SIDE+

POST-ICTAL CONFUSION+

H/O HEARING LOSS

NO H/O SIMILAR COMPLAINTS IN THE PAST.

NO H/O FEVER,COLD,COUGH ALLERGIES,ABDOMINAL PAIN,NAUSEA,VOMITING

K/C/O HEART FAILURE WITH MID RANGE EJECTION FRACTION(45%)?SECONDARY TO CAD ON T. ECOSPIRIN AV 75/40 OD AT 9PMCARDIVAS 3.125 MG BD

NON OLIGURIC AKI ON CKD X 9-10 YEARS ON CONSERVATIVE MANAGEMENT

K/C/O HYPERTENSION SINCE 3 YEARS ON TAB. TELMA 20 MG OD

K/C/O HYPOTHYROIDISM SINCE 1.5 YEARS ON T. THYRONORM 25MCG OD

FAMILY HISTORY:-INSIGNIFICANT

PERSONAL HISTORY:-

DIET-MIXED

SLEEP-ADEQUATE

ADDICTIONS-NIL

BOWEL AND BLADDER-REGULAR

ALLERGIES-NIL

GENERAL EXAMINATION:-

PATIENT IS

NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA

VITALS:-

BP-180/100 MM HG

RR-32 CPM

PR-80 BPM

TEMP-AFEBRILE

SPO2:-98 % AT RA

GRBS:-120 MG/DL

SYSTEMIC EXAMINATION:-

CVS:-S1 S2 HEARD ; NO MURMURS

RS:-BAE+ CREPITATIONS + IN B/L BASAL AREAS (MA, IAA, ISA)

P/A:- SOFT, NON TENDER, NO ORGANOMEGALY

CNS:-PATIENT IS STUPOROUS ; APHASIC.

GCS:-E2V2M3

TONE:- RIGHT LEFT

UL DECREASED DECREASED

LL DECREASED DECREASED

POWER RT LT

UL 1/5 3/5

LL 1/5 3/5

NOT MOVING RIGHT UPPER AND LOWER LIMBS TO PAIN STIMULLI

REFLEXES:- RIGHT LEFT

BICEPS - -

TRICEPS - -

SUPINATOR - -

KNEE - -

ANKLE - -

PLANTAR EXTENSION MUTE

PUPILS-BILATERAL PUPUILS NORMAL SIZE ; REACTING TO LIGHT

COURSE IN HOSPITAL : A 82 YR OLD MALE PT RESIDENT OF NARKETPALLY WAS LABOURER BY OCCUPATION A KNOWN CASE OF HEART FAILURE SECONDARY TO CAD ,CKD, HTN, COPD, HYPOTHYROIDISM PRESENTED TO CASUALTY WITH C/O UNRESPONSIVENESS SINCE 10 AM ON 29/05/2024 THOROUGH CLINICAL EVALUATION AND NECESSARY INVESTIGATIONS WERE DONE.VITALS ON PRESENATION PR: 80 BPM BP:180/100 RR:32CPM GRBS : 120 MG%,O/E TONE DECREASED IN BILATERAL UPPER LIMBS AND LOWER LIMBS

RT LT

POWER UL 1/5 3/5

LL 1/5 3/5

AREFLEXIA IN ALL THE JOINTS,DEEP TENDON REFLEXES ABSENT WITH PLANTAR EXTENSORS,MRI BRAIN WAS DONE WHICH SHOWED :ACUTE INFARCTS IN THE LEFT FRONTO-PARIETO -TEMPORAL REGION AND LEFT GANGLIO CAPSULAR REGION WITH CHRONIC SMALL VESSEL ISCHEMIC CHANGES.CHRONIC MICRO HEMORRHAGE IN RIGHT TEMPORAL REGION.CEREBRAL ATROPHY.PATIENT WAS STARTED ON DUAL ANTIPLATELETS , STATINS AND SUPPORTIVE CARE WAS GIVEN. AS PT HAD CONTINUOUS FEVER SPIKES AND BILATERAL CREPITATIONS WERE PRESENT IN BASAL AREAS HENCE PT WAS TREATED FOR ASPIRATION PNEUMONIA BLOOD AND URINE CULTURES WERE SENT.PT WAS STARTED ON NON INVASIVE VENTILATION THROUGHOUT THE DAY AND NIGHT .PT WAS DIAGNOSED WITH ALTERED SENSORIUM SECONDARY TO ACUTE INFARCT LEFT MCA TERRITORY FRONTO- PARIETO- TEMPORAL REGION WITH GTCS, WITH RIGHT HEMIPARESIS ; ASPIRATION PNEUMONIA ,HTN,CKD,COPD,HYPOTHYROIDISM ,HEART FAILURE WITH MID RANGE EJECTION FRACTION WITH PULMONARY EDEMA.ON DAY 2 AND 3 PT OXYGEN REQUIREMENT GRADUALLY IMPROVED AND TACHYPNOEA DECREASED.ON DAY 3, DUE TO CONTINUOUS FEVER SPIKES ANTIBIOTICS WERE ESCALATED AND DVT STOCKINGS WERE PRESCRIBED. ON DAY3 AROUND 11 PM PT DEVELOPED BRADYCARDIA HEART RATE 56 BPM- INJ ATROPINE 2CC IV STAT GIVEN.PT HAD DROP IN SATURATION 65% ON FIO2- 30% GRADUALLY FIO2 WAS INCREASED TO 60%.ABG WAS TAKEN WHICH SHOWED PH 7.081 PCO2 42.1 PO2 64.6 SPO2 87.4% HCO3 11.5HCO3P11.9 PT WAS INTUBATED AT AROUND 12 AM DUE TO PERSISTENT BRADYCARDIA AND FALL IN SATURATION AND PT WAS CONNECTED MECHANICAL VENTILATOR ON AC MC- VC MODE PT HAD PERSISTENT BRADYCARDIA AND FURTHER DROP IN HEART RATE AND SATURATION AT 12:40 AM ON 2/06/2024 AND PULSES AND BP NOT RECORDABLE HENCE CPR WAS STARTED ACCORDING TO LATEST ACLS GUIDELINES AND CONTINUED FOR 30 MINS INSPITE OF ABOVE RESUSCITATIVE EFFORTS PT COULDNT BE REVIVED AND DEATH WAS DECLARED AT 1:20 AM ON 2/06/2024--CAUSE OF DEATH -IMMEDIATE CAUSE OF DEATH -CVA WITH RIGHT HEMIPARESIS WITH ACUTE INFARCT IN LEFT MCA TERRITORY (FRONTO PARIETO TEMPORAL LOBES).GTCS,ASPIRATION PNEUMONIA.

ACUTE PULMONARY EDEMA ANTECEDENT CAUSE OF DEATH - CHRONIC LEFT VENTRICULAR FAILURE SECONDARY TO CAD,HTN,COPD,CKD.

Investigation

HAEMOGRAM

29/05/2024:

HB- 10.3

PCV-32.8

TLC-5400

RBC- 4.02

PLC:1.50 LAKHS

MCV- 81.6

MCH-25.6

(30/05/2024)

HB- 11.5

PCV-36

TLC- 7100

RBC- 4.51

PLC:1.5LAKHS

MCV- 79.8

MCH-25.5RBS 130 mg/dlLFT :TB :1.08DB :0.24AST: 22ALT :11ALP:303TP:6.8ALB3.8A/G RATIO 1.28RFT: (30/05/2024)UREA :33URIC ACID :4.9CREATININE: 1.4SODIUM :137CHLORIDE:99POTASSIUM:3.9CALCIUM:10PHOSPHORUS:4.3COMPLETE URINE EXAMINATION (CUE) (29-05-2024)COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NILBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil29-05-2024 :SEROLOGY NON REACTIVETHYROID PROFILE :T3 0.69T4 6.77TSH: 4.2ABG: (30/05/2024)PH :7.32PCO2 33.2PO2 45.5HCO3:16.9(31/05/2024)PH 7.3PCO2 38.6PO2 117HCO3 18.6(1/06/2024)PH 7.29;PCO2 33.8PO2:57.5HCO3:16(2/06/2024)PH 7.08PCO2 42.1PO2 64.6HCO3 :11.9BLOOD CULTURE AND SENSITIVITYNO GROWTH SEEN AFTER 48 HRS OF AEROBIC INCUBATION 2D ECHO (30/05/2024):GLOBAL HYPOKINESIA; MILD LVH +, MODERATE MR, MODERATE TO SEVERE AR,MODERATE TR WITH MILD PAHMAC +: CALCIFIED AV: NO AS/MSEJECTION FRACTION 50 FAIR LV SYSTOLIC FUNCTIONSMINIMAL PE + AND PLEURAL EFFUSION POSITIVEIVC SIZE 1.10 CM COLLAPSINGDILATED LA/RAMRI BRAIN PLAIN DONE( 29/05/2024)ACTIVE INFARCTS NOTED IN THE LEFT FRONTO-PARIETO - TEMPORAL REGION AND LEFT GANGLIO CAPSULAR REGIONCHRONIC SMALL VESSEL ISCHEMIC CHANGESCHRONIC MICRO HEMORRHAGE IN RIGHT TEMPORAL REGIONCEREBRAL ATROPHY

Treatment Given(Enter only Generic Name)

INJ.AUGMENTIN 1.2 GM IV/TID

INJ.METROGYL 500MG /IV/TID

INJ.PAN 40 MG IV OD

INJ.ZOFER 4MG /IV/TID

INJ.OPTINEURON 1 AMP IN 100 ML NS /IV/OD

INJ.NEOMOL 1GM/IV/SOS

INJ.LASIX INFUSION 3ML/HR(5MG/HR)

T.MODAFINIL 100MG /RT/OD

T.MET-XL 12.5MG/RT/OD

T.STROCIT PLUS/RT/BD

T.PULMOCLEAR /RT/BD

T.LEVIPIL 500 MG/RT/BD

T.BROMOCRIPTINE 2.5 MG TID

T.PCM 650 MG/RT/QID

T.ATORVASTATIN 40 MG/RT/OD

T.ECOSPRIN 75 MG/RT/OD

T.SHELCAL-XT /RT/OD

NEB WITH BUDECORT-6TH HOURLY

NEB WITH DUOLIN 6TH HRLY

Death Date

Date: 02/06/2024

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