CVA

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.

 

CASE PRESENTATION:

 

A 60year old female resident of bollaram , farmer by occupation  came to the hospital with the chief complaints of Drooling of saliva with slurring of speech since 7 days . weakness in the left upper and lower limb with deviation of mouth to right side since  6 days.

HOPI: 

 Patient  was apparently asymptomatic  4-5 years back , then she developed tingling and numbness sensation  Associatedw intermittent headache , neck pain, giddiness  for which she had been to a hosiptal  diagnosed with hypertension and was under medication (Tab ATEN 50mg od)

Suddenly she had deviation of mouth to right side with drooling of saliva. Associated with slurring of speech in the morning at 8:,00 am during breakfast   1 week back 

.

Then weakness of left upper limb since 6 days for which she tried lifting objects with left upper limb to regain her strength in that affected limb

Weakness of left lower limb since 4 days. Then after she was taken to nearby hospital where her BP was around 190/110 and CT scan was done showing an acute infarct in the right corona radiata and  treatment was given.

Inability to use her limbs which was sudden in onset  with progressive in nature. 

H/o pain in left hip joint and elbow joint.

No h/o trauma.

No h/o fever, diarrhoea, vomitings, cough, shortness of breath,  chestpain, orthopnea, paroxysmal nocturnal adyspnea, 

No h/o involuntary movements, neck stiffness, wasting or thinning of muscles.

PAST HISTORY:

 K/c/o hypertension since 4-5 years and is on tab. ATEN 50mg.

No h/o diabetes mellitus, epilepsy , bronchial asthma, chronic heart and kidney diseases, tuberculosis, thyroid disorders.

No previous surgeries and blood transfusion.

 

PERSONAL HISTORY: 

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder movements: regular.

No addictions.

FAMILY HISTORY: 

No significant family history.

DRUG HISTORY: 

Not allergic to any known drugs.

GENERAL EXAMINATION: 

Patient is conscious, coherent and cooperative.

Moderately built and moderately nourished.

No signs of pallor, icterus, cyanosis , clubbing, kilonychia, generalised lymphadenopathy, bilateral pedal edema.

 

VITALS:

Temperature: afebrile

Pulse rate: 80 beats per min

BP: 140/ 100 mm of hg

RR: 22 cycles per min.

Sp02 : 99% at room temperature

GRBS: 127 mg/dl.

SYSTEMIC EXAMINATION:

-CNS:

- Higher mental functions: conscious and alert with slurred speech.

- Spinomotor :   no wasting/ thinning of muscles. No  pain, fatigue and fasciculations.

                              Right.                 Left.

Bulk :.                      Normal.          Normal

Tone: 

      Upper limb:.     Normal.          Decreased

      Lower limb:.     Normal.          Decreased

Power:

      Upper limb:.     4+/5.                2</5

      Lower limb:.     4+/5.                3/5  

-Motor system

Reflexes:  

   Superficial reflexes: normal

   Deep tendon reflexes: 

      Biceps:.             +.                      ++

      Triceps:.            +.                      ++

      Supinator:.         -.                       +

      Knee:.                 -.                       ++

      Ankle:.                -.                        +

      Plantar:.             Withdrawal.    Extensor

 

-Sensory system:     right.   Left

                   Fine touch +.        -

               Vibration.      +.      -

            Position sense +.      -

           Crude touch.      +.      +

       pain and temperature +.  +

-Cranial nerve examination:

     Vll:  Deviation of mouth to right side.

            Drooling of saliva present 

            Able to close eyes.

           frowning present on both sides on forehead 

    Others cranial nerves: normal.

-ANS: Able to feel bladder fullness, regular bladder movements. No sweating and palpitations.

- Meninges: no fever, headache, neck stiffness, nausea and vomitings.

-PERABDOMINAL EXAMINATION:

 

Shape of abdomen: scaphoid

No tenderness and local rise of temperature.

No palpable masses.

Hernial orifices normal.

No free fluid and bruit.

Liver and spleen : not palpable.

Bowel sounds: normally heard.

 

-RESPIRATORY SYSTEM:

Position of trachea: normal

No wheeze and dyspnea.

Bilateral air entry present.

Normal vesicular breath sounds heard.

No adventitious sounds.

-CVS:

S1 and S2 heard.

No murmurs.

-Based on above findings, the following investigations were sent.

Hemogram

Hb:11 gms

RBC: 3.8 million

platelets 1.7 lakhs

WBC:10900

Smear:normocytic normochromic.

polymorpholeukocytosis

CUE:

colour:light yellow

appearance: slightly turbid

reaction:acidic

albumin: trace

sugar: nil

pus cells: 2-3/HPF

Epithelial cells: 1-2 /HPF

Parasite F: negative

 

CT brain report:  Acute infarct in right corona radiata. MCA territory.

MRI REPORT:

Acute infarct in right parietal and temporal lobe:MCA territory

serum creatinine 0.9 mg/ dl

sodium 142 mMol/ lit

potassium 3.9 mMol/lit

chloride 101 mMol /lit

RBS 134  mg/ dl

Blood urea 1.1 mg/ dl

serum uric acid 5.7 mg/ dl

LFT

Total bilirubin 0.9 mg/ dl

Direct bilirubin 0.1 mg/ dl

Indirect bilirubin 0.8 mg/ dl

SGPT 28 U/L

SGOT 34U/L

ALP 88 IU/ L

Total proteins 6.2 gms/ dl

Albumin 3.2 gms/ dl

Globulin 3.0 gms/ dl

A/G ratio 1.0

HIV Negative

HBsAg negative

VDRL negative

PT : 18 Sec

APTT:34 sec

INR : 1.3 Sec

BT: 2 min

CT : 4 min

ESR:57mm.

 

2d ECHO: normal

Carotid Doppler:  Proximal right ICA has a calcified plaque at the bulb, causing approx <20% occlusion with no significant stenosis.

Left ICA has small plaque causing no significant stenosis.

Xray pelvis with both hips: normal.

FLP:  Total cholesterol: 100

         Triglycerides: 83mg/dl

         Hdl cholesterol: 40 mg/dl

         Ldl cholesterol:  59 mg/dl

         Vldl : 16.6 mg/dl

PROVISIONAL DIAGNOSIS: 

 CVA - left side hemiparesis with acute infarct in right temporal and parietal lobe. With left UMN facial palsy involving MCA territory. 

K/c/o hypertension.

MANAGEMENT:

1) Tab. Aspirin 75 mg po/ od

2) Tab. Clopitab 75mg po/ od

3) Tab. Atorvastatin  20mg po h/s

4) Tab. Pregabalin 75mg h/s

5)  Inj. Optineuron 1amp in 500ml NS / IV / od

6)  Tab. Pan 40 mg po/ od

8) physiotherapy of left upper and lower limbs.

      

               

Status epilepticus

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.

CASE PRESENTATION:

A 33 year old female,resident of narketpally, housewife by occupation came with the chief complaint of Headache and neck pain since 3 days.

And. involuntary movements of all four limbs since evening 7:00 pm

HOPI:

Patient was apparently asymptomatic 3 days back, then she developed headache, associated with neckpain.  Pain was over occipital region , dragging type, constant throughout the day. Associated with tingling of lower and upper limbs. Also associated with blurring of vision. 

No diurnal variation, vomitings, neck stiffness, fever , diplopia.

-H/o fall at 5 pm,  with black outs, giddiness, with loss of  consciousness chest pain for 10 mins. Regained conscious and tried to walk.

At 8pm, they went to nearby rmp doctor and they were given medication.

-At that point She had an episode of seizures at 9pm with tonic clonic movements of right upper and lower limbs with  frothing from mouth. Loss of consciousness for 10 mins. 

Seizures were preceded by chest pain, palpitations, sweating, visual disturbance, 

No nausea, vomiting, sphincter incontinence, breathing pattern abnormality.

No tongue bite, deviation of mouth, uprolling of eye balls.

Recovered spontaneously  with confusion and residual weakness(?Todds paralysis)

There was an another episode of seizures after 10mins lasting for 10mins with generalized tonic clonic movements of all the 4 limbs. And brought to our hospital with on going seizures.

 Total no of seizures: 7-8 episodes in the hospital stay from 9:00 pm to next day morning 8:00 am each seizure episode lasting for 1-2 minutes with no complete regain of consciouness in between the seizure interval 

Sensorium between episode was drowsy but arousable.

No sustained injuries.

No speech abnormality.

 

PAST HISTORY:

K/c/o epilepsy. She had seizure activity 5 years ago and was under ayurvedic treatment  for 1 year and stopped.

No h/o hypertension, diabetes mellitus, chronic kidney disease, chronic heart disease, bronchial asthma, tuberculosis, thyroid disorders.

No h/o previous surgeries and blood transfusion.

PERSONAL HISTORY: 

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder movements: regular

No addictions

FAMILY HISTORY:

No similar complaints in the family

DRUG HISTORY:

Not allergic to any known drugs.

MENSTRUAL HISTORY: 

Age of menarche: 12 years.

She bleeds for 4 days for every 30 days. Cycles are regular with no pain and clots.

GENERAL EXAMINATION: 

Patient is in drowsy but arousable.

Patient is moderately built and moderately nourished.

No signs of pallor, icterus, cyanosis, clubbing, kilonychia, generalised lymphadenopathy, bilateral pedal edema.

VITALS:

Temperature: afebrile

Pulse rate: 63 beats per min

Respiratory rate: 36 cycles per min.

Blood pressure: 150/100 mm of hg

Spo2 : 98% at room temperature.

Grbs: 106 mg%.

 

SYSTEMIC EXAMINATION: 

-CNS:

-Higher mental functions:  

drowsy but arousable , normal speech.

- Spinomotor:   No wasting / thinning of muscles. No pain,fatique,fasciculations.

               Right.                  Left

Bulk.      Normal.              Normal

Tone.      Normal.              Normal

Power.   

     UL.     4/5.                          4/5

     LL.      4/5.                         4/5

Reflexes-

     Superficial:         

Corneal :       +.                     +

Conjunctival:   +.                     +

     Deep tendon reflexes

                     Right.                 Left

Biceps.           ++.                      ++

Triceps.          ++.                      ++

Supinator.     ++.                      ++

Knee jerk.     +++.                    +++

Ankle.             ++.                      ++

Plantar.          Flexor.             Flexor.

- Sensory system: no sensory deficit.

- Cranial nerves : 

1: no alternation in smell

2: blurring of vision present, able to differentiate colour.

3;4;6: no double vision . Able to move eyes in all directions

5: normal chewing of food . Sensation over face present

7: eye closure present

8. Hearing present , no tinnitus .

9,10. No difficulty in speech.

11. Normal neck movements in all directions.

12. Tongue rolling present.

-Cerebellar functions: Normal.

-ANS : Able to feel bladder fullness. Regular bowel movements, giddiness on waking up in the morning present. No sweating and palpitations.

-Meninges : No fever , nausea , vomiting or stiffness of neck.

-Perabdominal examination: 

Shape of abdomen - scaphoid and soft

No tenderness and local rise of temperature

No palpable mass,

Hernial orifices: normal

No free fluid and no bruit

Liver and spleen: not palpable

Bowel sounds: heard and normal.

-Respiratory system examination:

Position of trachea: central

No dyspnoea and wheeze

Bilateral air entry present.

normal vesicular breath sounds heard. 

 No adventitious sounds.

Cardiovascular system examination:

S1 and S2 heard, no murmurs.

Based on above findings , the following investigations were sent.

1) hemogram 

2) liver function test

3) kidney function test

4) complete urine examination

5) CT scan- brain. 

6) ECG

7) thyroid function test.

8) fundoscopy

9) serum magnesium

10) Random blood sugar 

11) EEG

            

         Fundoscopy : normal

       

         EEG : normal

PROVISIONAL DIAGNOSIS:

Recurrent epilepsy -? focal seizures progressed to GTCS.  

K/C/O epilepsy-non compliant to medication.

MANAGEMENT:

1) Inj. Levipil 2gm in 100ml NS / IV / stat.

2) Inj. Lorazepam 2cc/ IV/ stat , as seizures repeated 

4) Half hourly bp monitoring and head end elevation.

5) Inj. Eptoin 800mg in 100ml NS / IV/ stat over 30 mins. Followed by Inj EPTOIN 400 mg in 100 ml NS /IV / stat over 20 mins 

6) Inj. MgSO4 1amp in 500ml NS / IV over 2 hrs

7) Inj. Optineuron 1 amp in 100ml NS/ IV OD.

8) Inj. pcm 500mg im sos.

9) Inj. Pan 40mg IV OD.

10)  Inj. Zofer 4mg IV TID.

11)  IVF DNS @ 75ml per hour.

EEG done showing no abnormality 

Medicine attendance

Attendance from 23rd May to 8th June 2020.

  

Daily logs:

 

 23rd may : attented the case discussion of paraparesis- symmetrical bilateral lower limb weakness with sensory deficit. 

 

24th May :  Sunday read about paraparesis

 

25th May : collecting reports and monitoring of my unit patients. Read about reflexes.

26th May : collecting reports and monitoring of my unit patients. Read about stroke 

27th May : op day..

28th May : read about shock

29th May : case discussion about a male patient with sob, pedal edema since 1 week,  anuria since 3 days. Hfpef secondary to ? Hocm

30th May : case discussion about a patient with left gluteal abscess with cellulitis with intrinsic AKI .

31th May : Sunday.. monitoring  my unit patients.

1st June :  Monitoring patients. read about tingling , numbness , and burning sensation in both lower and upper limbs.

2nd June : holiday. Monitoring patients

3rd June : op day...

4th June : nephrology duty.. I did pleural tap.

 

5th June : nephrology duty.. I did ascitic tap.

 

6th June : nephrology duty.. monitoring patients.

7th June : Sunday

8th June : psychiatry posting -- opd cases - delirium, schizophrenia, depression.

Right heart failure

Hello everyone.....!! I am an intern in medicine department and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties.

CASE PRESENTATION:

A 45year old Male labourer came to the hospital  with the chief complaints of dribbling of urine since 1 week, burning micturition since 1week, shortness of breath since 1week. Anuria since 3 days.

 HOPI-
-  He was apparently asymptomatic 1 week back then he developed dribbling of urine associated with burning micturition without fever, low backache, suprapubic tenderness.
-Associated with B/L pedal edema upto knee of pitting type.
-Associated with shortness of breath grade 3 since 1 week progressed from grade 2 within 10 days.No h/o orthopnea and PND. No h/o palpitations, loss of consciousness,giddiness.
 -C/o constipation since 1 week not associated with obstipation. C/o nausea since 1 week with burning sensation in epigastrium, associated with decreased appetite

PAST HISTORY-
-no similar complaints in the past
-patient is not a k/c/o HTN,DM,CKD,CAD,epilepsy, asthma, TB

 DRUG HISTORY- not allergic to any known drugs.

FAMILY HISTORY- no similar complaints in the family

PERSONAL HISTORY:
diet-mixed
appetite-decreased
B&B- Irregular; anuria since 3 days, oliguria since 7 days ,constipation since 7days.
sleep-adequate
Addictions-alcoholic since 15 years & regular toddy drinker.

EXAMINATION-
GENERAL EXAMINATION:
Patient is conscious,coherent and cooperative.
Moderately nourished and built.
Temperature: afebrile
BP: 70/50 mm of hg measured in right arm in sitting position.
PR: 92 beats per min
RR: 28 cycles per min.
SpO2: 97% on room air
GRBS: 108mg%.
No signs of pallor, icterus, cyanosis, clubbing, kilonychia, generalised lymphadenopathy.
h/o bilateral pedal edema progressing upto knee.

RESPIRATORY SYSTEM EXAMINATION:
Dyspnoea- present [ grade 3 since 1week ]
Wheeze- no
Position of trachea- central
Breath sounds- vesicular
Adventitious sounds- no crepts and rales.

PERABDOMINAL EXAMINATION:
Shape : scaphoid, soft
no tenderness and  local rise of temperature.
no palpable mass
hernial orifice : normal
no free fluid , no bruits
liver and spleen - not palpable
bowel sounds- sluggish

CNS EXAMINATION:
Higher mental functions- normal
cranial nerves- normal
motor system- normal
sensory system - normal

CARDIOVASCULAR SYSTEM EXAMINATION:
1)Pulse- 92bpm, regular, low volume, condition of vessel normal, no radioradial delay and radiofemoral delay.
2)BP- 70/50 mm of hg
3) neck veins examination:  engorged
     JVP raised upto bifurcation of carotid.
    heart examination:
    - inspection:
       shape-normal
       apical impulse at 5th intercostal space in midclavicular line.
       no engorged superficial veins
       no scars, sinuses.
       no pulsations seen in other areas beyond precordium.
    - Palpation:
         a) mitral area:
             apex beat- 5th intercostal space in mid clavicular line
             no thrills.
         b) pulmonary area: normal
         c) aortic area: normal
         d) tricuspid area: normal
       
   -Auscutation:
          cardiac rate-92bpm
          rhythm-irregular
           S1 S2 heard
          no murmurs.

Based on the above findings, following investigations were sent
1) CBP
2) CUE
3) URINE culture and sensitivity
4) HIV, HBV, anti HCV
5) RFT
6) ESR
7) CXR- PA view(bedside)
8) ABG
9) 2d ECHO
10) ECG

Post cpr 2d echo

 

Pre cpr 2d echo

DIAGNOSIS: 

Decompensated right heart failure secondary to mild pulmonary artery hypertension. Anuria secondary to ? Bladder outlet obstruction. ? Ishaemic hepatitis. ? Cystitis. With hyperkalemia. ? Cardiorenal syndrome. With post renal AKI. With cardiogenic shock.

TREATMENT:
1) foleys catheterisation
2) salt(<2g /day) and fluid( 1.5 lts /day) restriction
3) head end elevation
4) oxygenation to maintain SpO2 > 95%
5) Inj. lasix 20mg bd if sbp> 110mmhg
6) Inj. noradrenaline 2 amp in 50 ml NS iv at 2ml/hr. 

 Patient was being monitored continuously for 14-15hrs , during which pt condition was worsened( GCS <7 , no carotid pulse) so cpr of 5 cycles done ,then pulse was restored. Pt was intubated due to falling saturation and low GCS (<3)

In some time , again the pt condition was worsened due to ventricular tachycardia so shock at 300j was given

7) infusion amiodarone
8) Inj. zofer 4mg iv tid
9) Inj. pantop 40mg iv bd
10) Tab. nodosis 500 mg p/o bd
11) syrup sucralfate 15ml p/o tid
12) syrup lactulose 15ml h/s
13) I/O charting and bp monitoring

14) inj. Tramadol 1 amp diluted in 20ml NS slow I/v over 5 mins sos

15) neb. Salbutamol 4 respules tid

16) I/v DNS 250ml with 6 units INSULIN i/v stat

17) tab. PAH 20mg p/o tid.

       

       Patient was shifted to higher centres with ambu bag and oxygen in ambulance upon the request of his attenders