A 60year old female with altered sensorium
Right upper limb and lower limb weakness since 5pm yesterday
HISTORY OF PRESENTING ILLNESS-
60 year old woman, vegetable seller by occupation who is a mother of 2 children, residing at Arvapally was apparently asymptomatic 10 years back when she had itching of her right thigh and upon scratching she developed right lower limb edema and was treated in our hospital for 3 months - ? History of Right lower limb cellulitis
Then she was even diagnosed to be a diabetic.
In the month of January this year, she developed generalised weakness along with dysnpea for which she was taken to a government hospital and she was treated for URTI and was discharged after 3 days.
Following week she started to experience dyspnea which aggravated on exertion and on supine position, PND + along with excessive sweating.
She also experienced low grade fever along with non productive cough back then.
She gradually developed weakness of right upper limb and lower limb as well. She was got to our hospital with these complaints and she was diagnosed to have DCMP with an EF of 25% and with Acute few hemorrhagic infarcts in her right frontal lobe. Her metabolic profile was normal.
After a stay in our hospital for a period of 5 days, she was discharged on Tab Metformin 500mg BD, Tab Ramipril 5mg OD, Tab Lasix 40mg BD, Tab Ecosprin 75mg OD, Tab Atorvas 20mg OD along with Inj HAI ( the attendant doesn't know how much she takes).
Following which she regained power of right upper and lower limbs and continued doing her daily activities. Yesterday while she was sitting on the chair and having a conversation with her husband she suddenly fell off from her chair and stopped responding to her attendants.
They also noticed that she was not raising her right upper and lower limb and she would intermittently open her eyes.
She was taken to an outside hospital and an MRI was done which showed acute infarct in left MCA territory along with chronic small vessel ischaemic changes and diffuse cerebral atrophy.
FAMILY HISTORY-
Not significant
PERSONAL HISTORY-
Diet-mixed
Appetite-decreased
Bowel and bladder movements-regular and normal
Addictions -none
Sleep -adequate
On examination:
VITALS-
Pallor +
PR - 85bpm
Bp - 120/70mmhg
Spo2 - 98%
Temp - 98.4 F
SYSTEMIC EXAMINATION-
Bilateral cataract+
GCS - E4 V2 M6
Power Right Left
UL 0 3+
LL 0 3+
Tone - Reduced in right upper and lower limb
Reflexes-
Right Left
B - 3+
T - 3+
S - 3+
K - -
A - -
P Extensor
No meningeal signs
Cvs - S1,S2 heard
Lungs- BAE +,NVBS heard
P/A-soft and non-tender
Diagnosis -
Acute Right MCA infarct
Known case of DCMP
Known case of Type 2 DM
15/9/2021
SOAP NOTES -17/9/2021
60 year old woman
Has been shifted from amc to ICU
Her sensorium has determined
S-patient is in altered sensorium
Gcs - E1V1M1
Corneal, Conjunctival reflex +
O-On examination:
Pallor +
PR - 62bpm
Bp - 120/70mmhg
Spo2 - 98%
Temp - 100 F
Stool passed 5 days back
Bilateral cataract+
GCS - E4 V2 M6
Power Right Left
UL 0 3+
LL 0 3+
Tone -
Reduced in right upper and lower limb
Reflexes-
Right Left
B + 3+
T + 3+
S + 3+
K - -
A - -
P Mute
No meningeal signs
Cvs - S1,S2
Lungs- BAE +
Diagnosis -
CVA with right hemiparesis secondary to ischaemic stroke with infarct in left fronto parietotemporal region with right capsuloganglionic region with (inv left mca territory)
History of CVA with right frontal region hemorrhagic infarcts
k/c/o dcmp with HfREF since 6 months
k/c/o type 2 DM since 10 years.
Plan of care-
Head end elevation
Ryeles tube feeds-100 ml milk 2nd hourly
100 ml water 2 nd hourly
Tab.ecospirin Av (75/20) HS
Inj.HAI according to sliding scale
Inj Lasix 20mg IV BD
Tab.pan 40mg IV OD
Syr.lactulose 10ml/BD
O2 inhalation
18/9/2021
The patient died at 8:07pm due to cardiac arrest
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