65/M WITH COMPRESSIVE MYELOPATHY, ACUTE INFARCT IN LEFT ANTERIOR TEMPORAL LOBE ? SPONDYLOARTHROPATHY, VASCULAR DEMENTIA-?MULTI INFARCT DEMENTIA.
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Here is a case I have seen
Unit 6:
Case admitted on 27/2/2021.
Interns
K. Nikhil reddy
K.Divya
M. Swarna
B.Manivarma
Juveria
Dr. Manasa(pgy1)
Dr. A. Vaishnavi (pgy2)
Dr. Sai Radha(pgy3)
Dr. Arjun (Asst. Prof)
Dr.Rakesh Biswas (HOD)
A 65 year old male , handloom Weaver and drama artist by occupation, now stopped working since 2 years came with complaints of lower backache since 5 years.
2 years back, with the death of his mother, patient went into depression,low mood, excessive crying for 4 months.
1.5 years back, patient found difficulty in getting up from squatting position, sudden in onset, rushed to hospital. No H/o slurring of speech, No H/o fall, No H/o Giddiness, No H/o involuntary movements, No bowel and bladder incontinence.MRI was done which showed ?infarcts.patient attenders said that patient has ? Joint disease? Clot in brain and asked them to review after 15 days.but, due to covid lockdown, Patient didn't approach medical consultation.
Since then, Patient walking with support(stick), has difficulty in getting up from sitting position, memory loss, unable to participate in active conversation , unable to express his feelings,no sleep disturbances.all these symptoms gradually progressive.
1 week back, patient developed
1.fever- high grade, associated with chills and rigors.
2.cough- productive, swallowed his sputum- couldn't expectorate, associated with shortness of breath after cough .
3.Decreased food and liquid intake
4. Difficulty in swallowing
5. Drooling of food particles, saliva.
No H/o vomitings, loose stools, cold.
Past history:
K/c/o DM since 5 years for which he is on regular medication ( Glimi M2 po/od)
K/c/o HTN since 10 years for which Patient is on clinidipine 10 mg od.
Chronic smoker since 50 years , smokes 1.5 packs of beedis /day to now 3-4 beedis/day.
Occasionally he tooks Alcohol.
No H/o TB,asthma, epilepsy, CAD.
Local examination:
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.
Temp:98.6F
PR:103 bpm
RR: 20cpm
BP:130/90 mmhg
Spo2:95% at room air.
Systemic examination:
CNS:
Patient is not oriented to time ,place ,person.
Speech-slurred
Cranial nerves- deviation of mouth to left- right facial hemiparesis, gag reflex+.
Motor examination:
Rt. Lt.
1.tone.
Upper limbs. Increased increased
Lower limbs. Normal. Normal
2.power
Upper limbs. 3/5. 3/5
Lower limbs. 2/5. 2/5
Hand grip. 100%. 100%
3. Reflexes
Corneal. Present. Present
Conjunctival. Present. Present
Biceps. +3. +3
Triceps. +3. +3
Supinator. +3. +3
Knee. +3. +3
Ankle +2. +2
Plantar. Extensor. Extensor
Sensory examination and cerebellar examination could not be assessed as patient is not oriented .
Neck rigidity. -+
Kernigs and brudzinski signs -. Negative.
CVS: S1, S2HEARD, no murmurs.
RS: BAE+,NVBS HEARD.
P/A: SOFT, NON TENDER, BOWEL SOUNDS+.
Investigations
Hemogram
CUE
LFT
MRI-WHOLE SPINE SCREENING
PROVISIONAL DIAGNOSIS:
COMPRESSIVE MYELOPATHY, ACUTE INFARCT IN LEFT ANTERIOR TEMPORAL LOBE ? SPONDYLOARTHROPATHY, VASCULAR DEMENTIA-?MULTI INFARCT DEMENTIA.
TREATMENT GIVEN:
1.RYLES TUBE FEEDING-200ML MILK EVERY 2ND HRLY.
2.IV FLUIDS 2 NS @75 ML/HR.
3.TAB. ECOSPRIN -AV(75/20MG)po/OD
4. TEMP. CHARTING 4TH HRLY.
On 28/2/2021.
S: NO FRESH COMPLAINTS.
FEVER,COUGH NOT SUBSIDED.
O: Patient not oriented to time, place ,person.
Temp:98.4F
BP: 160/100mmhg
PR:103 bpm
RR:24 cpm
GRBS:361 mg/dl.
CNS:
Speech-slurred
Cranial nerves- deviation of mouth to left- right facial hemiparesis, gag reflex+.
Motor examination:
Rt. Lt.
1.tone.
Upper limbs. Increased increased
Lower limbs. Normal. Normal
2.power
Upper limbs. 3/5. 3/5
Lower limbs. 2/5. 2/5
Hand grip. 100%. 100%
3. Reflexes
Corneal. Present. Present
Conjunctival. Present. Present
Biceps. +3. +3
Triceps. +3. +3
Supinator. +3. +3
Knee. +3. +3
Ankle +2. +2
Plantar. Extensor. Extensor
Sensory examination and cerebellar examination could not be assessed as patient is not oriented .
Neck rigidity. -+
Kernigs and brudzinski signs -. Negative.
CVS: S1, S2HEARD, no murmurs.
RS: BAE+,NVBS HEARD.
P/A: SOFT, NON TENDER, BOWEL SOUNDS+.
A:COMPRESSIVE MYELOPATHY, ACUTE INFARCT IN LEFT ANTERIOR TEMPORAL LOBE ? SPONDYLOARTHROPATHY, VASCULAR DEMENTIA-?MULTI INFARCT DEMENTIA.
P:
1.RYLES TUBE FEEDING-200ML MILK WITH PROTEIN POWDER EVERY 2ND HRLY.
2.INJ. MONOCEF 1GM/IV/BD.
3.TAB. ECOSPRIN -AV(75/20MG)po/OD
4. TEMP. CHARTING 4TH HRLY.
5. GRBS CHARTING 8TH HRLY.
6.INJ. PAN 40 MG IV/OD
7.INJ. HAI/SC ACCORDING TO SLIDING SCALE.
8. SYP. GRILINCTUS 5ML PO/BD.
9. IV FLUIDS 2 NS , 1 RL@ 75ML/HR.
On 1/3/2021
S: NO FRESH COMPLAINTS.
FEVER,COUGH SUBSIDED.
O: Patient not oriented to time, place ,person.
Temp:97.6F
BP: 150/80mmhg
PR:106 bpm
RR:22 cpm
GRBS:175 mg/dl.
CNS:
Speech-slurred
Cranial nerves- deviation of mouth to left- right facial hemiparesis, gag reflex+.
Motor examination:
Rt. Lt.
1.tone.
Upper limbs. Increased increased
Lower limbs. Normal. Normal
2.power
Upper limbs. 3/5. 3/5
Lower limbs. 2/5. 2/5
Hand grip. 100%. 100%
3. Reflexes
Corneal. Present. Present
Conjunctival. Present. Present
Biceps. +3. +3
Triceps. +3. +3
Supinator. +3. +3
Knee. +3. +3
Ankle +2. +2
Plantar. Extensor. Extensor
Sensory examination and cerebellar examination could not be assessed as patient is not oriented .
Neck rigidity. -+
Kernigs and brudzinski signs -. Negative.
CVS: S1, S2HEARD, no murmurs.
RS: BAE+,NVBS HEARD.
P/A: SOFT, NON TENDER, BOWEL SOUNDS+.
A:COMPRESSIVE MYELOPATHY, ACUTE INFARCT IN LEFT ANTERIOR TEMPORAL LOBE ? SPONDYLOARTHROPATHY, VASCULAR DEMENTIA-?MULTI INFARCT DEMENTIA.
P:
1. IV FLUIDS 2 NS , 1 RL@ 50ML/HR.
2. RYLES TUBE FEEDING-200ML MILK WITH PROTEIN POWDER EVERY 2ND HRLY.
3.INJ. MONOCEF 1GM/IV/BD.
4..TAB. ECOSPRIN -AV(75/20MG)po/OD
5. GRBS CHARTING 8TH HRLY.
6.INJ. PAN 40 MG IV/OD
7.INJ. HAI/SC ACCORDING TO SLIDING SCALE
8. PHYSIOTHERAPY OF BOTH LOWER LIMBS .
ON 2/3/2021.
S: NO FRESH COMPLAINTS.
FEVER,COUGH SUBSIDED.
O: Patient not oriented to time, place ,person.
Temp:97.6F
BP: 110/70mmhg
PR:86 bpm
RR:22 cpm
CNS:
Speech-slurred
Cranial nerves- deviation of mouth to left- right facial hemiparesis, gag reflex+.
Motor examination:
Rt. Lt.
1.tone.
Upper limbs. Increased increased
Lower limbs. Normal. Normal
2.power
Upper limbs. 3/5. 3/5
Lower limbs. 3/5. 3/5
Hand grip. 100%. 100%
3. Reflexes
Corneal. Present. Present
Conjunctival. Present. Present
Biceps. +3. +3
Triceps. +3. +3
Supinator. +3. +3
Knee. +3. +3
Ankle +3 +3
Plantar. Extensor. Extensor
Sensory examination and cerebellar examination could not be assessed as patient is not oriented .
Neck rigidity. -+
Kernigs and brudzinski signs -. Negative.
CVS: S1, S2HEARD, no murmurs.
RS: BAE+,NVBS HEARD.
P/A: SOFT, NON TENDER, BOWEL SOUNDS+.
A:COMPRESSIVE MYELOPATHY, ACUTE INFARCT IN LEFT ANTERIOR TEMPORAL LOBE ? SPONDYLOARTHROPATHY, VASCULAR DEMENTIA-?MULTI INFARCT DEMENTIA.
P:
1. IV FLUIDS 2 NS , 1 RL@ 50ML/HR.
2.TAB. ATORVAS 80 MG PO/HS,TAB. ASPIRIN 75mg po/OD.
3.INJ. MONOCEF 1GM/IV/BD.
4. GRBS CHARTING 8TH HRLY.
5.INJ. PAN 40 MG IV/OD
6.INJ. ACTRAPID 4U-4U-2U.
7.. PHYSIOTHERAPY OF BOTH LOWER LIMBS
8. FREQUENT CHANGE OF POSTURE TO PREVENT BED SORES.
9.NEOSPORIN POWDERFOR L/A ON BED SORES.
ON 3/3/2021.
S: NO FRESH COMPLAINTS.
FEVER,COUGH SUBSIDED.
O: Patient not oriented to time, place ,person.
BP: 140/70mmhg
PR:82 bpm
RR:22 cpm
CNS:
Speech-slurred
Cranial nerves- deviation of mouth to left- right facial hemiparesis, gag reflex+.
Motor examination:
Rt. Lt.
1.tone.
Upper limbs. Increased increased
Lower limbs. Normal. Normal
2.power
Upper limbs. 3/5. 3/5
Lower limbs. 3/5. 3/5
Hand grip. 100%. 100%
3. Reflexes
Corneal. Present. Present
Conjunctival. Present. Present
Biceps. +3. +3
Triceps. +3. +3
Supinator. +3. +3
Knee. +3. +3
Ankle +3 +3
Plantar. Extensor. Extensor
Sensory examination and cerebellar examination could not be assessed as patient is not oriented .
Neck rigidity. -+
Kernigs and brudzinski signs -. Negative.
CVS: S1, S2HEARD, no murmurs.
RS: BAE+,NVBS HEARD.
P/A: SOFT, NON TENDER, BOWEL SOUNDS+.
A:COMPRESSIVE MYELOPATHY, ACUTE INFARCT IN LEFT ANTERIOR TEMPORAL LOBE ? SPONDYLOARTHROPATHY, VASCULAR DEMENTIA-?MULTI INFARCT DEMENTIA.
P:
1. IV FLUIDS 2 NS , 1 RL@ 50ML/HR.
2.TAB. ATORVAS 80 MG PO/HS, TAB. ASPIRIN 75mg po/OD.
3.INJ. MONOCEF 1GM/IV/BD.
4. GRBS CHARTING 8TH HRLY.
5.INJ. PAN 40 MG IV/OD
6.INJ. ACTRAPID 4U-4U-2U.
7.. PHYSIOTHERAPY OF BOTH LOWER LIMBS
8. FREQUENT CHANGE OF POSTURE TO PREVENT BED SORES.
9.NEOSPORIN POWDERFOR L/A ON BED SORES.
10.INJ. HAI/SC ACCORDING TO SLIDING SCALE
11.TAB. CILNIDIPINE 100 MG PO/BD.
12.TAB.BACLOFEN10 MG PO/OD.
13.syp. LACTULOSE 15 ML PO/HS.
ON 4/3/2021.
S: NO FRESH COMPLAINTS.
FEVER,COUGH SUBSIDED.
O: Patient not oriented to time, place ,person.
BP: 110/80mmhg
PR:84 bpm
RR:22 cpm
CNS:
Speech-slurred
Cranial nerves- deviation of mouth to left- right facial hemiparesis, gag reflex+.
Motor examination:
Rt. Lt.
1.tone.
Upper limbs. Increased increased
Lower limbs. Normal. Normal
2.power
Upper limbs. 3/5. 3/5
Lower limbs. 3/5. 3/5
Hand grip. 100%. 100%
3. Reflexes
Corneal. Present. Present
Conjunctival. Present. Present
Biceps. +3. +3
Triceps. +3. +3
Supinator. +3. +3
Knee. +3. +3
Ankle +3 +3
Plantar. Extensor. Extensor
Sensory examination and cerebellar examination could not be assessed as patient is not oriented .
Neck rigidity. -+
Kernigs and brudzinski signs -. Negative.
CVS: S1, S2HEARD, no murmurs.
RS: BAE+,NVBS HEARD.
P/A: SOFT, NON TENDER, BOWEL SOUNDS+.
A:COMPRESSIVE MYELOPATHY, ACUTE INFARCT IN LEFT ANTERIOR TEMPORAL LOBE ? SPONDYLOARTHROPATHY, VASCULAR DEMENTIA-?MULTI INFARCT DEMENTIA.
P:
1.TAB. ATORVAS 80 MG PO/HS,
2.TAB. ASPIRIN 75mg po/OD.
3.INJ. MONOCEF 1GM/IV/BD.
4. GRBS CHARTING 8TH HRLY.
5.INJ. PAN 40 MG IV/OD
6.INJ. ACTRAPID 4U-4U-2U.
7.. PHYSIOTHERAPY OF BOTH LOWER LIMBS
8. FREQUENT CHANGE OF POSTURE TO PREVENT BED SORES.
9.NEOSPORIN POWDERFOR L/A ON BED SORES.
10.INJ. HAI/SC ACCORDING TO SLIDING SCALE
11.TAB. CILNIDIPINE 100 MG PO/BD.
12.TAB.BACLOFEN10 MG PO/OD.
13.syp. LACTULOSE 15 ML PO/HS.
14. TAB. CLOPIDOGREL 75MG PO/HS
ON 5/3/2021
S: NO FRESH COMPLAINTS.
FEVER,COUGH SUBSIDED.
O: Patient not oriented to time, place ,person.
BP: 140/80mmhg
PR:88 bpm
RR:20 cpm
CNS:
Speech-slurred
Cranial nerves- deviation of mouth to left- right facial hemiparesis, gag reflex+.
Motor examination:
Rt. Lt.
1.tone.
Upper limbs. Increased increased
Lower limbs. Normal. Normal
2.power
Upper limbs. 3/5. 3/5
Lower limbs. 3/5. 3/5
Hand grip. 100%. 100%
3. Reflexes
Corneal. Present. Present
Conjunctival. Present. Present
Biceps. +3. +3
Triceps. +3. +3
Supinator. +3. +3
Knee. +3. +3
Ankle +3 +3
Plantar. Extensor. Extensor
Sensory examination and cerebellar examination could not be assessed as patient is not oriented .
Neck rigidity. -+
Kernigs and brudzinski signs -. Negative.
CVS: S1, S2HEARD, no murmurs.
RS: BAE+,NVBS HEARD.
P/A: SOFT, NON TENDER, BOWEL SOUNDS+.
A:COMPRESSIVE MYELOPATHY, ACUTE INFARCT IN LEFT ANTERIOR TEMPORAL LOBE ? SPONDYLOARTHROPATHY, VASCULAR DEMENTIA-?MULTI INFARCT DEMENTIA.
P:
1.TAB. ATORVAS 80 MG PO/HS,
2.TAB. ASPIRIN 75mg po/OD.
3.INJ. MONOCEF 1GM/IV/BD.
4. GRBS CHARTING 8TH HRLY.
5.INJ. PAN 40 MG IV/OD
6.INJ. ACTRAPID 4U-4U-2U.
7.. PHYSIOTHERAPY OF BOTH LOWER LIMBS
8. FREQUENT CHANGE OF POSTURE TO PREVENT BED SORES.
9.NEOSPORIN POWDERFOR L/A ON BED SORES.
10.INJ. HAI/SC ACCORDING TO SLIDING SCALE
11.TAB. CILNIDIPINE 100 MG PO/BD.
12.TAB.BACLOFEN10 MG PO/OD.
13.syp. LACTULOSE 15 ML PO/HS.
14. TAB. CLOPIDOGREL 75MG PO/HS
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