A 75 year old female with altered sensorium secondary to infarct in Right frontoparietal region

 





A 75 year old female who is a resident of thatekal,nakrekal ,came to the casualty in the state of altered sensorium since 10 am in the morning on the day of admission (01/01/2024).

History of presenting illness:

Patient was apparently asymptomatic until today morning 8am (01/01/2024),then she had an episode of generalised tonic movements, which was lasting for 10 minutes and stopped by itself,which is also with post ictal confusion,No H/O level of consciousness. 
Next episode of seizures at 10am associated with deviation of mouth,frothing from mouth ,No involuntary micturition/ defecation and this followed by altered sensorium 
No H/O fever ,headache, neck pain prior to seizures. 

Past history:

Patient is a k/c/o epilepsy since 2 years ,but not taking any medication. 
K/c/o ? CVA,but not taking any medication 
K/c/o hypertension since 2 years ,taking medication
Not a k/c/o diabetes mellitus,asthma,CAD,Thyroid disorders,TB.

Treatment history:

Hypertension since 2 years, on medication 

PERSONAL HISTORY:

Diet -mixed
Appetite-normal
Sleep-adequate
Bowel and bladder movements -regular
Addictions -none
Allergies-none

FAMILY HISTORY:

No significant family history. 

GENERAL EXAMINATION:

Patient is stuporous
Speech - No response 

Temperature-afebrile
BP-160/80mmHg
PR-94bpm
RR-20cpm
Spo2-96@RA
GRBS-114mg/dl

No Pallor, cyanosis,clubbing lymphadenopathy,icterus,Pedal edema







CNS EXAMINATION:
(01/01/2024)

Cranial nerves- cannot be elicited

Motor system- cannot be elicited

                         .
                         Right                left
 
Tone :upper limb      ++              normal
          Lower limb          +                      +      

Sensory system-cannot be elicited 

Glasgow scale- E4 V1 M3

Reflexes absent in biceps,triceps,supinator, knee,ankle 
Plantar reflex- extension (B/L)

Cerebellar signs cannot be elicited 

(06/01/2024)

Glasgow scale- E4 V2 M6
Pupils mid dilated
               Right     left
  Power: upper limb      3/5       can't be elicited 
                     Lower limb      -      can't be elicited  

Tone: upper limb        ++            -        
Lower limb         +            -

Reflexes: biceps   - 2+          2+

                                    Triceps-     1+            1+ 
  
                             Supinator- 1+                       1+

                                            Knee-2+                       1+

              Ankle-   can't be elicited                        1+

Plantars- extension (B/L) 
                
      
                       .. 

CVS EXAMINATION:

S1 and S2 heard ,no murmurs present
Apex beat heard on left side 1cm medial to the midclavicular line.


PER ABDOMEN EXAMINATION:
soft and non tender ,no organomegaly present

RESPIRATORY EXAMINATION:
normal vesicular breath sounds present 

OPHTHAL REFERRAL ( 01/01/2024)
No evidence of hypertensive retinopathy 

PROVISIONAL DIAGNOSIS:

Altered sensorium secondary to infarct in Right Fronto parietal region with seizures (ischemic stroke) with old CVA (2 years back) with k/c/o hypertension (since 2 years)  with ? Aspiration pneumonia. 

INVESTIGATIONS:











MRI Brain:



2D ECHO:


USG ABDOMEN:
Grade 1 fatty liver
B/L grade 2 RPD changes

CAROTID ARTERY DOPPLER:
Plaque shown in the Right Common carotid artey
Atherosclerotic changes noted in the Common carotid artey, no stenosis 




TREATMENT:

1.RT Feeds with 100ml water 2nd hrly and 100ml milk + protein powder  4th hrly
2.IV fluids 1NS @30ml/hr
3.INJ.NEUROKIND 1 Amp in 100ml NS IV/OD
4.TAB.SODIUM VALPROATE 200MG RT/BD
5.TAB.ASPIRIN 75MG RT/OD
6.TAB.CLOPIDOGREL 75MG RT/OD
7.TAB.ATORVASTATIN 20MG RT/HS
8.TAB.OLKEM- TRIO (olmesartan 20mg +celnidipine  10mg+ chlorthalidone 6.25mg)
9.TAB.PAN 40MG RT/OD
10.NEB WITH SALBUTAMOL 8TH HRLY
11.Physiotherapy of both upper and Lower limbs





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