A 70yr old with Acute ischemic stroke of left parietal lobe with right sided hemiplegia with right upper limb focal seizures with aphasia with UMN facial palsy
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 70 yr old male patient came to the casualty with GCS of E4,V1,M5
H/o fever 7 days back,low grade, intermittent and associated with chills
H/o cough with expectoration, voluminous and mucoid
Intially c/o inability to lift right upper limb,and after 2 hrs he was unable to talk, identify his family members and unable to lift his left lower limb
Deviation of mouth to left side
No other complaints
PAST HISTORY:
H/o DM denovo
PERSONAL HISTORY
Appetite normal
Regular Bowel and bladder movements
Drinks alcohol since 30 yrs( takes 90 ml whiskey daily)
GENERAL EXAMINATION
Patient is
No pallor icterus ,cyanosis, clubbing, lymphadenopathy
VITALS:
Temp:98.6
PR:82bpm
BP:100/70mm hg
RR: 16 cpm
Spo2-92%
CVS:
S1,S2 heard,no murmurs
RS: position of trachea :central
BAE present
B/L infraclavicular expiratory wheeze
B/L inspiratory crepitations
PER ABDOMEN: soft and non tender
Bowel sounds+
CNS:
Patient is conscious,not oriented to time ,place and person and not co-operative
Speech: aphasic
No meningeal signs
Cranial nerves:
Deviation of mouth to the left side and loss of nasolabial folds on right side
Reflexes : rt. Left
B. Absent Absent
T. Absent Absent
S. Absent Absent
K. Absent 2+
A. Absent Absent
Plantar reflex exaggerated on both sides
Provisional diagnosis:
Acute ischemic stroke on left parietal lobe
Clinical images:
Radiological investigations:
12/10/21:
Investigations:
10/10/21:
11/10/21:
12/10/21:
13/10/21:
Treatment :
Soap notes -11/10/21
S- pt is disoriented
Objective:
Pt is drowsy
Afebrile
PR:84 bpm
BP: 130/70 mmHg
CVS: S1, S2 heard
RS: BAE present ,NVBS
P/A: soft ,non tender ,bowel sounds present
CNS: E2V1M3
Speech:Aphasic
Orientation:Time(-)
Place (-)
Person(-)
Tone : normal b/l
Motor: power rt lt
UL 0/5 5/5
LL 0/5 5/5
ASSESSMENT-Acute ischemic infarct in left parietal lobe (evolving?)
Plan of care:
1)IVF - 1 NS @50ml/hr
2) Inj Thiamine in 100ml NS/IV/TID
3) Tab Ecosprin AV /75/20mg PO/H/S
4) Tab Clopidogrel 75mg/PO/H/S
5) Ryles tube feeding every 4rth hourly
- 100ml water
- 100 milk with protein powder
6)Physiotherapy for right UL and RL
7) Vital monitoring -4rth hrly
Soap notes-12/10/21
S- pt is disoriented
Objective:
Pt is drowsy
Afebrile
PR:84 bpm
BP: 130/70 mmHg
CVS: S1, S2 heard
RS: BAE present ,NVBS
P/A: soft ,non tender ,bowel sounds present
CNS: E2V1M3
Speech:Aphasic
Orientation:Time(-)
Place (-)
Person(-)
Tone : normal b/l
Motor: power rt lt
UL 0/5 5/5
LL 0/5 5/5
Reflexes B T S K A P
R - 1+ - - - T
L - - - - - T
ASSESSMENT-Acute ischemic stroke in left parietal lobe (evolving?)
(R) Hemiplegia with UMN facial palsy
With (R) UL focal seizures.
Plan of care:
1)IVF - 1 NS @50ml/hr
2) Inj Thiamine in 100ml NS/IV/TID
3) Inj Lorazepam 2cc IV/SOS
4) Inj Monocef 1gm/IV/BD
5) Tab Ecosprin AV /75/20mg PO/H/S
6) Tab Amlong 10mg/PO/OD
7) Tab Eptoin 100mg RT/PO/TID
8) Ryles tube feeding every 4rth hourly
- 100ml water
- 100 milk with protein powder
9)Physiotherapy for right UL and RL
10)Vital monitoring -4rth hrly
Soap notes-(13/10/21)
Subjectively - patient is having sob
Objectively
Gcs :E2V1M4
Temp:101 F
PR:112 bpm
BP:120/70mm hg
RR: 24 cpm
Spo2-99% on 15 L of o2
CVS:
S1,S2 heard,no murmurs
RS: BAE present
B/L Basal crepitations present
P/a: soft and non tender
CNS: Patient is drowsyand aphasic
Tone : decreased on all 4 limbs.
Power 3+/5 on left side and 0/5 on right side
Reflexes : All absent
Plantar reflex exaggerated on both sides.
Provisional diagnosis:
CVA : Right side hemiparesis with right umn fascial palsy with ischemic stroke on left frontal ,parietal lobe, temporal, occipital lobes : Left MCA territory
Treatment:
1)IVF - 1 NS @50ml/hr
2) Inj Thiamine in 100ml NS/IV/TID
3) Inj Lorazepam 2cc IV/SOS
4) Inj Monocef 1gm/IV/BD
5) Tab Ecosprin AV /75/20mg PO/H/S
6) Tab Amlong 10mg/PO/OD
7) Tab Eptoin 100mg RT/PO/TID
8) Ryles tube feeding every 4rth hourly
- 100ml water
- 100 milk with protein powder
9)Physiotherapy for right UL and RL
10)Vital monitoring -4rth hrly
Soap notes-14/10/21
Subjectively - patient is having sob
Objectively
Gcs :E2V1M4
Temp:99 F
PR:102 bpm
BP:130/80mm hg
RR: 24 cpm
Spo2-99% on 15 L of o2
CVS:
S1,S2 heard,no murmurs
RS: BAE present
B/L Basal crepitations present
P/a: soft and non tender
CNS: Patient is drowsyand aphasic
Tone : decreased on all 4 limbs.
Power 3+/5 on left side and 0/5 on right side
Reflexes : All absent
Plantar reflex exaggerated on both sides.
Provisional diagnosis:
CVA : Right side hemiparesis with right umn fascial palsy with ischemic stroke on left frontal ,parietal lobe, temporal, occipital lobes : Left MCA territory
Treatment :
1)IVF - 1 NS @50ml/hr
2) Inj Thiamine in 100ml NS/IV/TID
3) Inj Lorazepam 2cc IV/SOS
4) Inj Monocef 1gm/IV/BD
5) Tab Ecosprin AV /75/20mg PO/H/S
6) Tab Amlong 10mg/PO/OD
7) Tab Eptoin 100mg RT/PO/TID
8) Ryles tube feeding every 4rth hourly
- 100ml water
- 100 milk with protein powder
9)Physiotherapy for right UL and RL
10)Vital monitoring -4rth hrly
Soap notes-16/10/21
S-Spontaneous eye opening present.
turning towards verbal stimuli
No seizure episode
Objectively
Gcs :E4V1M4
Temp:99.5 F
PR:102 bpm
BP:150/90mm hg
RR: 24 cpm
Spo2-98% on 6 L of o2
CVS:
S1,S2 heard,no murmurs
RS: BAE present
B/L Basal coarse crepitations present.
P/a: soft and non tender .
CNS: Patient is drowsy with intermittent spontaneous eye opening present.
Pupils - b/l NSRL.
Tone : decreased on all 4 limbs.
Power 4-/5 on left side and 0/5 on right side
Reflexes : All absent
Plantar reflex extensor on both sides.
Provisional diagnosis:
CVA : Right side hemiplegia with right umn facial palsy with Global aphasia .
Acute ischemic stroke on left frontal ,parietal lobe, temporal, occipital lobes : Left MCA territory.
Focal seizures of right upperblimb and trunk .
Treatment:
1)IVF - 1 NS @50ml/hr
2) Inj Thiamine in 100ml NS/IV/TID
3) Inj Lorazepam 2cc IV/SOS
4) Inj Monocef 1gm/IV/BD
5) Tab Ecosprin AV /75/20mg PO/H/S
6) Tab Amlong 10mg/PO/OD
7) Tab Eptoin 100mg RT/PO/TID
8) Ryles tube feeding every 4rth hourly
- 100ml water
- 100 milk with protein powder
9)Physiotherapy for right UL and RL
10)Vital monitoring -4rth hrly
Soap notes 17/10/21:
S-Spontaneous eye opening present.
turning towards verbal stimuli
No seizure episode
Objectively
Gcs :E4V1M4
Temp:99.5 F
PR:102 bpm
BP:150/90mm hg
RR: 24 cpm
Spo2-98% on 6 L of o2
CVS:
S1,S2 heard,no murmurs
RS: BAE present
B/L Basal coarse crepitations present.
P/a: soft and non tender .
CNS: Patient is drowsy with intermittent spontaneous eye opening present.
Pupils - b/l NSRL.
Tone : decreased on all 4 limbs.
Power 4-/5 on left side and 0/5 on right side
Reflexes : All absent
Plantar reflex extensor on both sides.
Provisional diagnosis:
CVA : Right side hemiplegia with right umn facial palsy with Global aphasia .
Acute ischemic stroke on left frontal ,parietal lobe, temporal, occipital lobes : Left MCA territory.
Focal seizures of right upperblimb and trunk .
Treatment:
1)IVF - 1 NS With optineurin @50ml/hr
1 RL @ 75ml/hr
2) Inj Thiamine in 100ml NS/IV/TID
3) Tab Levipil 500mg/RT/BD
4) Tab Ecosprin AV /150/40mg PO/H/S
5) Tab Amlong 10mg/RT/OD(if SBP>160mmhg)
6) Ryles tube feeding every 4rth hourly
- 100ml water
- 100 milk with protein powder
7) Nebulisation with Duolin-8th hourly
With budecort-12th hrly
With mucomist-8th hrly
8) Grbs monitoring-8th hrly
9)Physiotherapy for right UL and RL
10)Vital monitoring -4rth hrly
11) INJ HAI S/C TIDTID(acc to Grbs)
8am-2pm-8pm
Soap notes- 18/10/21:
Spontaneous eye opening present .
Drooling of saliva present.
Objectively:
Gcs:E4V1M4
Temp:99.5f
Pr:98bpm
Bp-130/70mmhg
Rr-24cpm
SpO2-96% on ra
Grbs-200mg/dl ---6 units hai given
Cvs: s1s2 heard, no murmurs
RS:BAE+
B/L basal coarse crepitations Present
P/a:soft and non tender
CNS:patient is conscious
Pupils: b/l nsrl
Tone: decreased on right side
Power:4/5 on left side And 0/5 on right side
Plantar reflex extensor on both sides
Provisional diagnosis:
CVA :right side hemiplegia with right umn facial palsy with global aphasia.
Acute ischemic stroke on left frontal, parietal, temporal, occipital lobes:Left MCA territory
Focal seizures of right Upper limb and trunk.
Treatment:
1) Ryles tube feeding every 4rth hourly
- 100ml water
- 100 milk with protein powder
2) Tab Ecosprin AV /150/40mg PO/H/S
3) Tab Amlong 5mg/RT/OD
4) Tab Levipil 500mg RT/BD
5) Nebulisation with Duolin-8th hourly
With budecort-12th hrly
With mucomist-8th hrly
6) Grbs monitoring-8th hrly
7)Physiotherapy for right UL and RL
8)Vital monitoring -2nd hrly
9) INJ HAI S/C TIDTID(acc to Grbs)
8am-2pm-8pm
Patient Discharged on 18/10/21:
Advise at discharge-
1) Ryles tube feeding every 4rth hourly
- 100ml water
- 100 milk with protein powder
2) Tab Ecosprin AV /150/40mg PO/H/S
3) Tab Amlong 5mg/RT/OD
4) Tab Levipil 500mg RT/BD
5) Nebulisation with Duolin-8th hourly
With budecort-12th hrly
With mucomist-8th hrly
6) INJ HAI S/C TIDTID(acc to Grbs)
8am-2pm-8pm
7) )Physiotherapy for right UL and RL
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