80 YEAR OLD MALE WITH ALTERED SENSORIUM

21st April, 2022

ICU ADMISSION

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80 year old male farmer by occupation residing in miryalguda came with chief complaints of
- altered sensorium since afternoon
- aphasia, right upper limb weakness since 5 'o clock in the evening 

HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic till 12:30pm today. After 12:30pm, patient first complained of weakness followed by inability to walk and then slowly the weakness started worsening and by 5:00pm in the evening, the patient could not speak and could not move his right upper limb and from 6:00pm, the patient had c/o incontinence of urine

PAST HISTORY : 
Not a k/c/o hypertension, diabetes, asthma, epilepsy, TB, thyroid

PERSONAL HISTORY :
Diet - mixed
Sleep - adequate
Appetite - normal
Alcoholic - abstinence from alcohol since 4years

GENERAL EXAMINATION :
Patient is drowsy
No pallor, icterus, cyanosis, lymphadenopathy 
BP - 140/70 mm Hg
PR - 101 bpm
RR - 17 cpm
Spo2 - 94% on RA
GRBS - 133 mg/dl

Systemic examination :
CVS - S1 S2 +
RS - BAE+
P/A - soft, nontender
CNS - 
Patient is drowsy
Spontaneous movements of left upper and lower limbs
Right upper limb - no movements 
Right lower limb - decreased movements 
Tone - 
. Left upper and lower limbs : normal
. Right upper limb : hypotonia
. Right lower limb : hypertonia
Reflexes - Right        Left
. Biceps :   2+            2+
. Triceps :  2+            2+
. Supinator : 2+         2+
. Knee :     absent      absent
. Ankle :    absent      absent
. Plantar : mute         mute

INVESTIGATIONS : 
SEROLOGY - NEGATIVE

DIAGNOSIS : 
- MULTIPLE INFARCTS IN LEFT MCA, ACA 
- AF WITH FVR
- CARDIOEMBOLIC STROKE

TREATMENT :
1. TAB ECOSPORIN 150MG OD R/T
2. TAB CLOPITAB 75MG R/T OD
3. TAB ATOCOR 40MG R/T OD
4. INJ AMIODARONE 150MG STAT F/B
300MG (2AMP) IN 50ML NS @ 8ML/HR FOR 6HRS F/B
600MG (4AMP) IN 50ML NS @ 2.8ML/HR FOR 18HRS
5. IVF : NS, RL, DNS @ 75ML/HR
6. RT FLUID 200ML MILK WITH PROTEIN POWDER, 50ML FREE WATER 1ST HRLY
7. I/O CHARTING, MONTIOR VITALS, GRBS MONITORING 6TH HRLY
8. INJ CEFTRIAXONE 1GM IV/BD
9. TAB PAN 40MG OD
10. NEB IPRAVENT 8TH HRLY, BUDECORT 12TH HRLY

SOAP NOTES DAY 2
ICU BED 1

S:
NO FRESH COMPLAINTS.

O-
PATIENT IS DROWSY
No PALLOR, ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 
TEMPERATURE - 98.2F
PULSE RATE - 71 bpm
BP - 110/80 mmHg
RESPIRATORY RATE - 17 cpm
SPO2 - 98% @ RA

SYSTEMIC EXAMINATION - 
PER ABDOMEN : SOFT, NO ORGANOMEGALY
CARDIOVASCULAR SYSTEM : 
S1 AND S2 HEARD , IRREGULAR SKIPBEATS+
RESPIRATORY SYSTEM : BAE+, LUNGS CLEAR 
CENTRAL NERVOUS SYSTEM : PT IS DROWSY
POWER- SPONTANEOUS MOVEMENTS IN LEFT UL &LL
ABSENT MOVEMENTS IN RT UPPER LIMB & DECREASED MOVEMENTS IN RT LOWER LIMBS.
TONE: NORMAL- IN BOTH  LEFT UL&LL 
RIGHT : UL- HYPOTONIA 
               LL- HYPERTONIA

A:
CVA, RIGHT HEMIPARESIS, ATS, MULTIPLE INFRACTS ON MRI IMAGING
CARDIAC EMBOLIC STROKE. 
 
P:
1) TAB ECOSPRIN 150MG OD R/T
2) TAB CLOPITAB 75MG RT OD R/T
3)TAB ATOCOR 40MG RT OD
4) IV FLUIDS NS,RL,DNS @ 75ML/HR
5)RT FEEDS - 200ML  MILK WITH PROTEIN POWDER 2ND HOURLY
-50ML FREE WATER 1st HOURLY
6) INJ CEFTRIAXONE 1GM IV/BD
7) TAB PAN 40MG OD BBF
8) NEB WITH IPRAVENT 8TH HOURLY
-BUDECORT- 12TH HOURLY.
9) INJ HEPARIN 5000IU TID
10) TAB CARDARONE 100MG TID

SOAP NOTES DAY 3
ICU BED 1

S:
NO FRESH COMPLAINTS.

O-
PATIENT IS CONSCIOUS 
No PALLOR, ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 
TEMPERATURE - 98.2F
PULSE RATE - 95bpm
BP - 130/70mmHg
RESPIRATORY RATE - 17 cpm
SPO2 - 98% @ RA

SYSTEMIC EXAMINATION - 
PER ABDOMEN : SOFT, NO ORGANOMEGALY
CARDIOVASCULAR SYSTEM : 
S1 AND S2 HEARD 
RESPIRATORY SYSTEM : BAE+, LUNGS CLEAR 
CENTRAL NERVOUS SYSTEM : PT IS CONSCIOUS
POWER- SPONTANEOUS MOVEMENTS IN LEFT UL &LL
ABSENT MOVEMENTS IN RT UPPER LIMB & DECREASED MOVEMENTS IN RT LOWER LIMBS.
TONE: NORMAL- IN BOTH  LEFT UL&LL 
RIGHT : UL- HYPOTONIA 
               LL- HYPERTONIA
REFLEXES : RIGHT          LEFT
BICEPS - 2+                    2+
TRICEPS - 2+                2+
SUPINATOR - 2+          2+
KNEE -  ABSENT        ABSENT
ANKLE - ABSENT      ABSENT
PLANTAR - MUTE      MUTE

INVESTIGATIONS : 
Hb-8.5  TLC-9700  PLATELETS-2.83
S.CREATIININE-1.2
S.ELECTROLYTES : Na-137  K-4.1  Cl-98

A:
CVA, RIGHT HEMIPARESIS, ATS, MULTIPLE INFRACTS ON MRI IMAGING
CARDIAC EMBOLIC STROKE. 
 
P:
1) TAB ECOSPRIN 150MG OD R/T
2)TAB ATOCOR 40MG RT OD
3) IV FLUIDS NS,RL,DNS @ 75ML/HR
4)RT FEEDS - 200ML  MILK WITH PROTEIN POWDER 2ND HOURLY
-50ML FREE WATER 1st HOURLY
5) INJ CEFTRIAXONE 1GM IV/BD
6) TAB PAN 40MG OD BBF
7) NEB WITH IPRAVENT 8TH HOURLY
-BUDECORT- 12TH HOURLY.
8) INJ HEPARIN 5000IU TID
9) TAB CARDARONE 100MG TID


SOAP NOTES DAY 4
ICU BED 1

S:
NO FRESH COMPLAINTS.

O-
PATIENT IS CONSCIOUS 
No PALLOR, ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 
TEMPERATURE - 98.6F
PULSE RATE - 89bpm
BP - 140/80mmHg
RESPIRATORY RATE - 17 cpm
SPO2 - 98% @ RA

SYSTEMIC EXAMINATION - 
PER ABDOMEN : SOFT, NO ORGANOMEGALY
CARDIOVASCULAR SYSTEM : 
S1 AND S2 HEARD 
RESPIRATORY SYSTEM : BAE+, LUNGS CLEAR 
CENTRAL NERVOUS SYSTEM : PT IS CONSCIOUS
POWER- SPONTANEOUS MOVEMENTS IN LEFT UL &LL
ABSENT MOVEMENTS IN RT UPPER LIMB & DECREASED MOVEMENTS IN RT LOWER LIMBS.
TONE: NORMAL- IN BOTH  LEFT UL&LL 
RIGHT : UL- HYPOTONIA 
               LL- HYPERTONIA
REFLEXES : RIGHT          LEFT
BICEPS - 2+                    2+
TRICEPS - 2+                2+
SUPINATOR - 2+          2+
KNEE -  ABSENT        ABSENT
ANKLE - ABSENT      ABSENT
PLANTAR - MUTE      MUTE

A:
- MULTIPLE INFARCTS ON MRI IMAGING - LEFT EXTERNAL WATERSHED TERRITORY, CAUDATE AND THALAMUS
- AF WITH FVR
- CARDIOEMBOLIC STROKE
- OSTEOARTHRITIS OF BOTH KNEES (R>L) 

P:
1) TAB ECOSPRIN 150MG OD 
2)TAB ATOCOR 40MG  OD
3) IV FLUIDS NS,RL,DNS @ 75ML/HR
4) INJ CEFTRIAXONE 1GM IV/BD
5) NEB WITH IPRAVENT 8TH HOURLY
-BUDECORT- 12TH HOURLY.
6) INJ HEPARIN 5000IU TID
7) TAB CARDARONE 100MG TID

SOAP NOTES DAY 5
AMC BED 2
26/4/2022

S:
NO FRESH COMPLAINTS.

O-
PATIENT IS CONSCIOUS 
No PALLOR, ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 
TEMPERATURE - 98.6F
PULSE RATE - 80bpm
BP - 120/70mmHg
RESPIRATORY RATE - 17 cpm
SPO2 - 98% @ RA

INVESTIGATIONS :
PT - 16SEC
APTT - 33SEC
INR - 1.11
SERUM UREA - 40
SERUM CREATININE - 1.1

SYSTEMIC EXAMINATION - 
PER ABDOMEN : SOFT, NO ORGANOMEGALY
CARDIOVASCULAR SYSTEM : 
S1 AND S2 HEARD 
RESPIRATORY SYSTEM : BAE+, LUNGS CLEAR 
CENTRAL NERVOUS SYSTEM : PT IS CONSCIOUS
POWER- SPONTANEOUS MOVEMENTS IN LEFT UL &LL
ABSENT MOVEMENTS IN RT UPPER LIMB & DECREASED MOVEMENTS IN RT LOWER LIMBS.
TONE: NORMAL- IN BOTH  LEFT UL&LL 
RIGHT : UL- HYPOTONIA 
               LL- HYPERTONIA
REFLEXES : RIGHT          LEFT
BICEPS - 2+                    2+
TRICEPS - 2+                2+
SUPINATOR - 2+          2+
KNEE -  ABSENT        ABSENT
ANKLE - ABSENT      ABSENT
PLANTAR - MUTE      MUTE

A:
- MULTIPLE INFARCTS ON MRI IMAGING - LEFT EXTERNAL WATERSHED TERRITORY, CAUDATE AND THALAMUS
- AF WITH FVR
- CARDIOEMBOLIC STROKE
- OSTEOARTHRITIS OF BOTH KNEES (R>L) 

P:
1) TAB ECOSPRIN 150MG OD 
2)TAB ATOCOR 40MG  OD
3) INJ CEFTRIAXONE 1GM IV/BD
4) NEB WITH IPRAVENT 8TH HOURLY
-BUDECORT- 12TH HOURLY.
5) INJ HEPARIN 5000IU TID
6) TAB CARDARONE 100MG TID

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