79 y/o male with Recurrent CVA and left hemiplegia with Aspiration pneumonia and seizures disorder

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COMPLAINTS AND DURATION:

A 79 y/o male was brought to casuality with c/o cough since 1 & half month , 

fever since 10 days

difficulty in swallowing and h/o Aspiration pneumonia since one month

C/o altered sensorium since 3 days

HOPI 

Patient is a known case of cva with left hemiplegia, DM type 2 , Hypertension, Thyroid disorders, and bronchial asthma. 

 Patient was apparently asymptomatic one and half month back when he developed cough insidious in onset and gradually progressive. PRODUCTIVE but patient is not able to spit it out. Difficulty in swallowing.

 H/o cough on intake of liquids.

 H/o change of voice since 20 days, insidious, hoarse in character and 

 SLURRING OF SPEECH +present

No h/o difficulty in breathing,  breathlessness, hemoptysis

 Fever since 10 days -high grade. O/e Chills and rigors + (38 spikes).

H/O WEAKNESS in LEFT upper and lower limb since 4 years aggrevated since 4 days.

 N/h/o vomiting, chest pain, loose stools.

PAST HISTORY  

 Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is  on medications I.e tab TELMA AM 40mg po/od.  Tab zoryl mv , po/od

 History of events:-

 • 10 years back , patient developed lesions on his both foot and went to the doctor and found to have diabetes and started on medication.and after 1 year ,with regular check up he was found to be Hypertensive  and started on antihypertensive medication.

 • 7 years back, patient developed head ache at around evening 7pm and followed by vomtings, next day morning onwards patient became drowsy and cannot move his limbs and was taken to the hospital and found to have infarct and started on antiplatelets.

  K/c/o CVA with left hemiplegia since 7 years. 

   K/c/o seizures disorder since 2 years for which on medications Tab levipil 500mg

  K/c/o hypothyroidism since 5 years on thyronorm 25mcg.

• From 7 years onwards , patient was bedridden with foleys (changed every 15 days) and physiotherapy was done by his attenders daily, but there was no such improvement.

• 20 days back, from March 1st onwards ,patient developed slurring of speech and decreased responsiveness and cough ( mild ) and unable to clear the throat secretions and was taken to the hospital and was treated with antibiotics and patient was brought here for further evaluation.

PERSONAL HISTORY 

Appetite lost, 

Mixed diet

Bowel- constipated, 

Bladder regular 

No known allergies and Addictions.

 i.e non alcoholic and non smoker

Family History-  not any

Treatment history   

 

•Tab TELMA AM 40mg po/od since past   10years

 •Tab zoryl mv , po/od

•Tab levipil 500mg since 2 years

• thyronorm 25mcg. Since5 years

GENERAL EXAMINATION 

O/e PT IS arousable but not oriented.

Pt not cooperative mostly. 

-PALLOR: PRESENT

-NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS ON ADMISSION 

PR-90 BPM

BP- 140/80MM HG

RR- 22 CPM

SPO2- 98% AT RA

GRBS - 183mg/dl

SYSTEMIC EXAMINATION:

Respiratory :-

Inspection :  

palpation : 

Auscultation :

percussion - BAE +

                       B/L GRUNTING +

                        ICA, ISA, SSA

CNS

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

GCS - E3V3M5

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,

CRANIAL NERVES- cannot be elicited 

 SENSORY SYSTEM- cannot be elicited 

MOTOR SYSTEM:

  •TONE- hypotonic 

  •POWER- cannot be elicited 

  • B/L REFLEXES: 

BICEPS,  TRICEPS, SUPINATOR,  KNEE  ANKLE - hypotonia

 PLANTARS- hypotonia

CVS

ASCULTATION: S1S2 +,NO MURMURS

P/A

INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

AUSCULTATION: no bowel sounds heard

CLINICAL IMAGES 

C/o  smth hemiscrotum

O/e  

bed sores

C/o asymptomatic lesions all over the body since 2 months

H/o application of unknown topical medications used

O/e multiple hyperpigmented Macclesfield present all over the body with scaly lesions over the upper back

•Diffuse xerosispresent

• single ulcer of size 1.5x1.5 cms (approx) over the back.

Diagnosis SENILE XEROSIS + post inflammatory hyperpigmentation.

( +? TROPHIC ULCER )

INVESTIGATIONS 

MRI BRAIN- 

OBSERVATIONS:

• Large area of encephaolomalacia in right occipito -temporo lobes and righ parietal lobes.

• Prominence of sulci and cisterns. 

• Bilateral periventricular hyperintensity.

• Rest of the Cerebral parenchyma shows normal gray/white matter differentiation.

• Basal ganglia and Thalami are normal.

• Brain stem normal.

• Cranio-vertebral and Cervico-medullary junctions are normal.

• Sella, pituitary and parasellar regions are normal. Stalk and hypothalamus are normal. Posterior pituitary bright spot is normal.

• No evidence of abnormal calcifications, vascular anomalies on SWI sequences.

IMPRESSION:

• Large area of encephalomalacia in right occipito-temporo lobes and right parietal lobes - sequelae of old infarct.

• Diffuse cerebral atrophy. Chronic small vessel ischemia.

Note: Poor quality of images due to motion artefacts

CUE :-

AFB-TRACE

PUS CELLS -2-4

EPITHELIAL CELLS -2-3

Usg abdomen - 

1) b/l mild hilar prominence - likely pulmonary artery Hypertension. 

(Co relatewith 2D echo)

2D ECHO  

CBP.                                                   

RFT 

LFT 

DIAGNOSIS 

Recurrent CVA with Hypertension, T2 DM, Thyroid disorder, BRONCHIAL ASTHMA, and seizures disorder. 

TREATMENT 

1) TAB ECOSPRIN 150 mg RT/OD

 2) TAB CLOPIDOGREL 75 MG RT/OD 

3) TAB ATORVAS 20 MG RT/OD

4) NEBULISATION - 3% NS ,

                                 MUCUMZY 8th hourly 

5) CHEST PHYSIOTHERAPY.

6) RT FEEDS 100 ML WATER 2nd HRLY

                        50 ML Milk 2nd HRLY.

7) INJ HAP SC | TID / premeal a/l to GRBS 

8) TAB. THYRONORM 25MCG RT/OD

9) TAB. LEVIPiL TOOMG RT/OD