A 50year old M with weakness in left upper and lower lobe

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        CASE DISCUSSION

A 50yrs old  who is a resident of cheruvu gattu came with c/o weakness in  left UL and LL since 05/05/23 morning At 8:00AM

HOPI-

patient was apparently asymptomatic till today morning and attenders noticed that he couldn't get up from bed and complained of weakness in left UL and LL which is of sudden onset and gradually progressive.

-No h/o loss of consciousness, involuntary movements, drooling of saliva, involuntary micturation and defecation.

 Daily routine- patient wakes up at 6:00Am in the morning and freshens up and to heis sister in law for breakfast and tea and returns home ,watches Tv and have lunch at 12:30PM and sleep in the afternoon and have tea at 5:00 Pm and have dinner at 8:00pm.

Past history-

K/C/O Acute CVA (Rt.hemiparesis) 2yrs back.

 -1yr back  came to OPD with c/o urinary incontinence ,drooling of saliva.

 Took medication and left.

 K/C/O  HTN and DM since 2yrs and  on regular medication.

T.metformin 500mg + glimiperide 1mg Po/od (morning)

T.metformin 500mg +po/of

T.Amlong 2.5mg po/od

PERSONAL HISTORY:

Diet- mixed

Appetite - normal

Sleep -normal

Bowel and bladder -regular

Addictions-

-He is chronic alcoholic since 30 years, stopped 2 years  after  right hemiplegia.

-he chews tobacco since 10 years .

FAMILY HISTORY:

No similar complaints in the family.

TREATMENT HISTORY:

He is on antihypertensives and metformin

GENERAL EXAMINATION:- 

GCS - E4,V4,M5

-B/L pupils - NSRL

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - absent 

Vitals :- 

Temp - 97.2F

BP - 110/70 mm Hg

Pulse rate - 72 bpm

Respiratory rate - 14 cycles per minute 

SYSTEMIC EXAMINATION:

 CNS EXAMINATION :-

Motor system

Power:-

Rt UL - 3/5 Lt UL -0/5

Rt LL - 3/5  Lt LL -0/5

Tone:-

Rt UL - Hyper

Lt LL-Hypo

Rt LL-Hyper

Lt LL- Hypo

Reflexes: 

                   Right                    Left

Biceps:      ++                    +++

Triceps:       ++                  +++

Supinator:  +++                    ++

Knee:         +++                    ++

Ankle:            +                   +

Plantar:      flexor.         Extensor

Involuntary movements - absent

Fasciculations - absent

Sensory system - 

-Pain, temperature, crude touch, pressure sensations,Fine touch, vibration, proprioception -normal

Cerebellum - 

Finger nose test , dysdiadochokinesia, Rhomberg test could not elicited.

Autonomic nervous system - normal

• Meningeal sign  

Neck stiffness -present 

Brudzinski sign -present

Kernings sign -present.

ABDOMEN EXAMINATION:

Inspection -

Umbilicus - inverted

All quadrants moving equally with respiration

No scars, sinuses and engorged veins , visible

 pulsations.

CVS EXAMINATION 

S1,S2 heard,no murmurs.

Respiratory system examination

Bilateral air entry present.

Investigations :

ECG

MRI

USG -

Impression

Raised echogenicity of left kidney

Grade 1 fatty liver

X-Ray chest-

Consolidatory changes noted in the right lateral aspect of mid and lower zone of lung.

On 06/05/23

 ophthalmology referral was done-Reviewed i/v/o diabetic and hypertensive retinopathy changes and also raised ICP features.

Impression -normal anterior segment,No view  because of thick posterior subscapular cataract

On 07/05/23

TLC count started increasing and was initially started on inj.monocef,pitas,clindamycin

On 09/05/23

Pulmonology referral was done-

Reviewed I/v/o- consolidatory changesnoted in the right lateral aspect of mid and lower zone of lung.

Advised tab.Mucinac 600mg TID RT

Tab.Azithromycin 500mg OD RT

On 09/05/23 there was sudden fall in spo2 levels and there was an impending decision for intubation but later spo2levels maintained.

Right middle and lower zone consolidation (resolving) with acute liver injury (resolving)

 

10/11/23

11/05/23

2D echo

Mild TR with PAH;Mild AR;No MR

No RWMA No AS/MS,sclerotic AV

Good LV systolic function

Diastolic dysfunction ,no PE. 

Review 2d echo

Doppler impression-

Raised CIMT in b/l CCA's

b/l CCA and ICA show normal biphasic  wave pattern,calibre and colour uptake

No e/o plaques in b/l CCA'S and ICA'S.

Lumbar puncture done on 06/05/23 at 8:30pm

Fever chart-

Day wise investigation chart-

Haemogram and RFT

15/05/23

16/05/23

17/05/23

18/05/23

19/05/23

20/05/23

23/03/23

24/05/23

25/05/23

26/04/23

27/05/23

28/05/23

29/05/23

30/05/23

31/5/23

01/05/23

2/06/23

OP physiotherapy assessment proforma

Culture and sensitivity

Urine culture

Blood culture

CSF c/s

LFT

CUE

Referral (ophthalmology)

(Pulmonology)

Diagnosis-

Left hemiplegia sec  to Acute infarct in right superior parietal lobule;Superior frontal gyrus with Right middle and lower zone consolidation(resolved ) with acute liver injury(resolved) with  UTI.

K/c/o Right hemiparesis in 2020.

K/c/o HTN and Type 2 DM since 2yrs.

Grade 2 bedsore on Right buttock and left buttock with natal cleft

Treatment : 

1.i.v. Fluids NS  at 75ml/hour

2.RT Feeds 

-100ml water every 2nd hourly

-200ml Milk+ 2 spoons protein powder every 4th hourly.

4.Inj.  Clexane 40mg/SC/OD

5.Inj.Human actrapid insulin S/C acc to  grbs>200mg/dl

6.Tab. Ecosprin gold 75/75/10 RT/HS

7.Tab.Amlong 10mg RT/OD

8.Nebulisation with

-Ipravent 6th hourly

-budecort 12th hourly

-mucomist 6th hourly

9.Tab. nodosis 500mg PO/BD 

10.Tab. Nicardia 10mg SOS

11.Ointment mega-heal for L/A over bedsore

12.chest physiotherapy before every feed

13.physiotheraphy-passive movements, streching exercises

14.Frequent change in position

15.syp.LACTULOSE 15ml/RT/HS.

16.Neosporin powder for L/A over bedsore 

17.Ointment Thrombophobe

Discharge summary 

COURSE IN THE HOSPITAL -

Patient is admitted i/v/o weakness in left UL and LL since morning and on further evaluation MRI was found to have  acute infarct in right superior parietal lobule,superior frontal gyrus,centrum semiovale,peri ventricular white matter-External watershed territory infarct.

Encephalomalacia with gliotic changes in left  frontal lobe extending to periventricular white matter

K/c/o right hemiparesis in 2020.

On admission

GCS- E4,V3,M5

MRI was found to have  acute infarct in right superior parietal lobule,superior frontal gyrus,centrum semiovale,peri ventricular white matter-External watershed territory infarct.Encephalomalacia with gliotic changes in left  frontal lobe extending to periventricular white matter.

O/E

Temp - 97.2F

BP - 130/80 mm Hg

Pulse rate - 90bpm

Respiratory rate - 20 cycles per minute 

SYSTEMIC EXAMINATION:

ABDOMEN EXAMINATION:

Inspection -

Umbilicus - inverted

All quadrants moving equally with respiration

No scars, sinuses and engorged veins , visible

 pulsations.

CVS EXAMINATION 

S1,S2 heard,no murmurs.

Respiratory system examination

Bilateral air entry present.

CNS Examination 

B/L pupil NSRL

Power:-

Rt UL - 3/5 Lt UL -0/5

Rt LL - 3/5  Lt LL -0/5

Tone:-

Rt UL - Hyper

Lt LL-Hypo

Rt LL-Hyper

Lt LL- Hypo

Superficial reflexes-

Corneal /conjunctival reflex -normal 

Abdominal reflex-normal

Deep reflexes

Jaw reflex- present

Reflexes: 

                   Right                    Left

Biceps:      ++                    ++

Triceps:       +              +

Supinator:  +                  +

Knee:         ++                  ++

Ankle:            +                   +

Plantar:      decreased    increased

Kernig sign-positive

Brudzinski's sign -positive

LP done

On 06/05/23 

CSF analysis showed no cells 

CSF culture and sensitivity-blood C/S no growth after 24hr of aerobic incubation

Urine C/S-E.Coli>10 power 5 CFU/ML of urine isolated

X-Ray chest-

Consolidatory changes noted in the right lateral aspect of mid and lower zone of lung.

On 06/05/23

 ophthalmology referral was done-Reviewed i/v/o diabetic and hypertensive retinopathy changes and also raised ICP features.

Impression -normal anterior segment,No view  because of thick posterior subscapular cataract

On 07/05/23

TLC count started increasing and was initially started on inj.monocef,pitas,clindamycin

On 09/05/23

Pulmonology referral was done-

Reviewed I/v/o- consolidatory changes noted in the right lateral aspect of mid and lower zone of lung.

Advised tab.Mucinac 600mg TID RT

Tab.Azithromycin 500mg OD RT

On 09/05/23 there was sudden fall in spo2 levels and there was an impending decision for intubation but later spO2 levels maintained.

Right middle and lower zone consolidation (resolving) with acute liver injury (resolving)

Presently on the day of discharge 

GCS - E3,V2,M3

vitals

BP - 140/90 mm Hg

Pulse rate - 127bpm

Respiratory rate - 35CPM

SPO2 -97% at room air

LE

SYSTEMIC EXAMINATION:

ABDOMEN EXAMINATION:

Inspection -

Umbilicus - inverted

All quadrants moving equally with respiration

No scars, sinuses and engorged veins , visible

 pulsations.

CVS EXAMINATION 

S1,S2 heard,no murmurs

Respiratory system examination

Bilateral air entry present.

CNS EXAMINATION 

B/L pupil NSRL

Power:-

Rt UL - 3/5 Lt UL -0/5

Rt LL - 3/5  Lt LL -0/5

Tone:-

Rt UL - Hyper

Lt LL-Hypo

Rt LL-Hyper

Lt LL- Hypo

Superficial reflexes-

Corneal /conjunctival reflex -normal 

Abdominal reflex-normal

Deep reflexes

Jaw reflex- present

Reflexes: 

                   Right                    Left

Biceps:      ++                    ++

Triceps:       +              +

Supinator:  +                  +

Knee:         ++                  ++

Ankle:            +                   +

Plantar:      decreased    increased

29.5.2023

Vitals : 

BP- 130/90mm Hg

PR -118bpm

RR- 48cpm

Spo2- 99% on RA

GRBS - 152mg/dl

Temperature -98.4F

I/O :- 2800/1850ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE present,grunting +

P/A: soft, non tender,bowel sounds can be heard 

CNS:

B/l pupils - NSRL

Gcs: E4,V2,M3

 Reflexes:

         R       L

B    +2      +2

T   +2       +2

S    +2       +2

K.  +.       +

A   +       +

P   Flexion  Flexion 

Tone:

         Rt      Lt

UL.  Hyper hyper

        Hyper hyper

Power:

         Rt.         Lt

UL.    3/5.      0/5

 L L    3/5.     0/5

A: 

Left hemiplegia secondary to Acute infarct in right superior parietal lobule;Superior frontal gyrus  with Right middle and lower zone consolidation(resolved ) with acute liver injury(resolved) with  UTI.

K/c/o Right hemiparesis in 2020.

K/c/o HTN and Type 2 DM since 2yrs.

Grade 2 bedsore on Right buttock and left buttock with natal cleft

P: 

1.i.v. Fluids NS  at 75ml/hour

2.RT Feeds 

-100ml water every 2nd hourly

-200ml Milk+ 2 spoons protein powder every 4th hourly.

4.Inj.  Clexane 40mg/SC/OD

5.Inj.Human actrapid insulin S/C acc to  grbs>200mg/dl

6.Tab. Eco-sprin gold 75/75/10 RT/HS

7.Tab.Amlong 10mg RT/OD

8.Nebulisation with

-Ipravent 6th hourly

-budecort 12th hourly

-muco mist 6th hourly

9.Tab. nodosis 500mg PO/BD 

10.Tab. Nicardia 10mg SOS

11.Ointment mega-heal for L/A over bedsore

12. Suction every hourly

13.chest physiotherapy before every feed

14.physiotheraphy-passive movements, streching exercises

15.Frequent change in position

03/06/2023

Ward : AMC

Unit : 5

DOA : 05/05/23

S

-c/o weakness in left UL and LL still present 

-No fresh complaints

- No Fever spikes 

-Stools passed

O: 

Patient is drowsy 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy, pedal edema

Vitals : 

BP- 120/80 mm Hg

PR -115bpm

RR- 40cpm

Spo2-  98%

GRBS - 138mg/dl

Temperature -98.4F

I/O :- 2000/1000ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE present,B/L grunting +

P/A: soft, non tender,bowel sounds can be heard 

CNS:

B/l pupils - NSRL

Gcs: E4,V2,M3

 Reflexes:

         R       L

B    +2      +2

T   +2       +2

S    +2       +2

K.  +.       +

A   +       +

P   Flexion  Flexion 

Tone:

         Rt      Lt

UL.  Hyper hyper

        Hyper hyper

Power:

         Rt.         Lt

UL.    3/5.      0/5

 L L    3/5.     0/5

A: 

Left hemiplegia secondary to Acute infarct in right superior parietal lobule;Superior frontal gyrus  with Right middle and lower zone consolidation(resolved ) with acute liver injury(resolved) with  UTI.

K/c/o Right hemiparesis in 2020.

K/c/o HTN and Type 2 DM since 2yrs.

Grade 2 bedsore on Right buttock and left buttock with natal cleft

P: 

1.i.v. Fluids NS  at 75ml/hour

2.RT Feeds 

-100ml water every 2nd hourly

-200ml Milk+ 2 spoons protein powder every 4th hourly.

4.Inj.  Clexane 40mg/SC/OD

5.Inj.Human actrapid insulin S/C acc to  grbs>200mg/dl

6.Tab. Eco-sprin gold 75/75/10 RT/HS

7.Tab.Amlong 10mg RT/OD

8.Nebulisation with

-Ipravent 6th hourly

-budecort 12th hourly

-mucomist 6th hourly

9.Tab. nodosis 500mg PO/BD 

10.Tab. Nicardia 10mg SOS

11.Ointment mega-heal for L/A over bedsore

12.chest physiotherapy before every feed

13.physiotheraphy-passive movements, streching exercises

14.Frequent change in position