14.

 Case History and Clinical Findings

PRESENTING COMPLAINTS:

Fever since 12 days.

Burning micturition since 12 days.

HOPI A 65 year male, apparently asymptomatic 12 days back then he had gradual onset of fever since 12

days initially high grade fever associated with chills, history of burning micturition on day 3 of illness.

Patient sought for consultation at local Rmp and treated with oral medication. On day 4 of illness, the

patient was brought to another local hospital for further management, there he was treated with iv

Fluids for 3days. As fever didn't subside, patient was shifted to another hospital; there he was treated

with IV antibiotics and 1 unit of platelet transfusion was done in view of low platelet count. During the

transfusion of platelet patient had chills. From next day of transfusion patient developed slurred

speech and was reffered to our hospital in view of hemodialysis. Now admitted for further evaluation

and management.

Past history:History of CAD 6yrs agoHistroy of platelet transfusion on 24/10/22

Not k/c/o DM ,HTN, Asthma,Epilepsy.

Personal history:

Diet : mixed

Appetite decreased

Bowel and bladder movements - constipation since 3 days

Consumes alcohol 180ml once in 2 weeks stopped since 6yrs

Smokes bedi 7 per day since age of 20 yrs

Family history insignificant

General physical examination:

Patient conscious, Oriented to time ,and persons but not to place on day of admission

No pallor ,icterus,cyanosis, clubbing, lymphadenopathy , oedema of feet

VITALS:

Temp :99°f

Pulse rate:86 bpm

Resp.rate- 16cpm

Bp- 130/80mmhg

Spo2-95%RA

GRBS:253mg/dl

SYSTEMIC EXAMINATION

CVS: S1, S2 +, no thrills and murmurs

PER ABDOMEN- soft,non tender, bowel sounds+ , umbilicus central inverted , no scars and sinuses.

RS: BAE+,NVBS, no added sounds heard

CNS- HMF intact.pupil- B/L normal size reacting to light.Speech- improvedDeviation of mouth to

rightTongue fasiculations present

Cranial nerve :7th - Deviation of mouth to rightTongue fasiculations , wrinking right> left

MOTOR :

POWER:- Upperlimb LowerlimbRight - 5/5 5/5Left - 5/5 5/5TONE:- upperlimb LowerlimbRight -

Hypertonia >HypertoniaLeft - Hypertonia >HypertoniaTone of right limbs greater than

leftREFLEXES:Biceps +2 of both limbsTriceps +1 of both limbsSupinator +1 of both limbsKnee +2 of

both limbsAnkle -right limb mute &leftlimb +1Plantar - flexion both limbsSENSORY :BILATERAL:

TOUCH , PAIN ,TEMP +Cerebellar signs are absent.Gait - short stepping gaitNIHSS_ 13 points,

moderate

CNS EXAMINATION AT THE DISCHARGE:

CNSHMF intact.pupil- B/L normal size reacting to light.Speech- improvedDeviation of mouth to

rightTongue fasiculations present

Cranial nerve :7th - Deviation of mouth to rightTongue fasiculations , wrinking right> left

MOTOR :

POWER:- Upperlimb LowerlimbRight - 5/5 5/5Left - 5/5 5/5TONE:- upperlimb LowerlimbRight -

Hypertonia >HypertoniaLeft - Hypertonia >HypertoniaTone of right limbs greater than

leftREFLEXES:Biceps +2 of both limbsTriceps +1 of both limbsSupinator +1 of both limbsKnee +2 of

both limbsAnkle -right limb mute &leftlimb +1Plantar - flexion both limbsSENSORY :BILATERAL:

TOUCH , PAIN ,TEMP +Cerebellar signs are absent.Gait - short stepping gaitNIHSS_ 13 points,

moderate

COURSE IN THE HOSPITAL: A 65 year male clinically presenyed to the casuality with above mentioned complaints. Upon

admission initial neurological examination showed right sided weakness and same side facial palsy.

MRI BRAIN stroke protocol was done which showed Acute Left Frontal lobe infract. Necessary

investigations were done. Patient was shifted to AMC and haded over to the ICU team. Hemogram on

admission was Hb ; TLC cells/mm3; platelet count lakhs/mm3. The patient waas found to be having

high post lunch blood sugars and HbA1c 7.2; for which he was started on insulin and his blood sugars

were monitored. During the stay in hospital he was treatred with oral anti platelet, antipyretic and

other supportive medications. Physiotherapy was advised and done. At the time of discharge his

hemogram wasHb ; TLC cells/mm3; platelet count lakhs/mm3. His condition was gradually improved

and was discharged in a hemodynamically stable condition.

Investigation

2D ECHO: (DONE ON 26/10/22)

RWMA+ ,( LAD &LCX HYPOKINESIA)

MODERATE TR WITH PAH(55MMHG)

MILD MR; TRIVIAL AR

SCLEROTIC AV, NOAS/MS

EF-43% MODERATE LV DYSFUNCTION

DIASTOLIC DYSFUNCTION, NO PE

IVC SIZE- NORMAL

ON 27/10/22:

RWMA+ ,( LAD &LCX HYPOKINESIA)

MODERATE TR WITH PAH(55MMHG)

MILD MR; TRIVIAL AR

SCLEROTIC AV, NOAS/MS

EF-43% MODERATE LV DYSFUNCTION

DIASTOLIC DYSFUNCTION, NO PE

IVC SIZE- NORMAL

DILATED- LV

MILD DILATED - LA

USG (ON 26/10/22)

B/L GRADE 1 RPD CHANGES WITH B/L RENAL CORTICAL CYSTS

Diagnosis ACUTE ISCHEMIC STROKE OF LEFT FRONTAL LOBE SECONDARY TO ?POST SDP TRNSFUSION ?DENGUE VASCULITIS RIGHT UMN FACIAL PALSY; HYPERKALEMIA(RESOLVED); NON OLIGURIC AKI(RESOLVED); MILD ANEMIA; CAD - TO LAD,LCX (6 YEARS AGO); DENOVO TYPE II DM

Treatment Given(Enter only Generic Name)

1) INJ. ZOFER 4MG/BD 2) INJ. NEOMOL 1GM/IV/ SOS IF TEMP @>101°F

3) TAB ECOSPRIN 75MG/PO/OD@ 2PM

4) TAB ATROVAS 40 MG /PO/HS

5) TAB DOLO 650MG /PO/BD

6)TAB PAN 40MG PO/OD

7) VITALS , GRBS ,I/O

8) T.METFORMIN 500MG/PO/0D

9) SURUP ARISTOZYME 15ML/PO/TID

10) PHYSIOTHERAPY

Advice at Discharge

1) TAB ECOSPRIN 75MG/PO/OD@ 2PM

2) TAB ATROVAS 40 MG /PO/HS

3) T.METFORMIN 500MG/PO/0D

4) HOME MONITORING OF BLOOD SUGARS