80 YRS OLD MALE CAME TO CASUALTY WITH C/O LOSS OF CONSCIOUSNESS (FOR HALF AN HOUR) C/O INVOLUNTARY BOWEL AND BLADDER INCONTINENCE AND SLURRED SPEECH SINCE 4AM TODAY

 

80 yrs old Male came to casualty with 

C/O loss of consciousness (for half an hour)

C/O involuntary bowel and bladder incontinence and slurred speech since 4am today(19/12/21)


HOPI


Patient was apparently asymptomatic till 4:00am today got up from bed and walked to washroom ,while walking near the door at 4:00am,patient slipped and fell on the ground-sustained injury to back and head.

He had loss of consciousness for half an hour and then regained.Conscious spontaneous with no involuntary movements,froth from mouth.

H/O involuntary micturition and defecation present 

H/O slurred speech present after fall

On presentation patient is conscious,confused,slurred speech present.


Past history 


N/K/C/O HTN,DM,TB,epilepsy,CVA,CAD


Personal history 

Diet -mixed

Appetite-normal

Bowel movements-irregular 


He is a toddy drinker and smokes chutta 


Family history 

Not significant 


General examination 

Pt is conscious 

 conscious 






Vitals

Temp-Afebrile 

Bp-120/60mmHg

PR-90bpm

Spo2-99% on RA


Systemic examination 


CVS-S1,S2 +

RS- BAE+,NVBS

P/A-soft,non tender

CNS-

He is conscious and confused 

Speech is slurred 


Motor examination

Tone -increased on rt side

Reflexes-

          Rt.          Lt 


       B. 2+.          +

       T. 2+.          +

       S. 2+.          +

       K. 3+.          +

       A. 3+.          +

Planters-B/L mute


Sensory examination 

Flexion movement to pain


Provisional diagnosis 

Acute ischemic stroke (Lacunar infarct) 

Frontal occipito-temporal lobe 

DENOVO HTN, DM II

H/O Chronic smoker and alcoholic

GRADE 2

Investigations








On 20/12/21

CBP


Serum electrolytes





Treatment 

1. Inj.  Mannitol 100 ml IV/STAT

2. Inj. Lasix 80 mg IV/STAT

3. Inj. Actrapid 10U in 25%D over 45min

4. Inj. Labetalol 20 mg IV/STAT

5. Neb with salbutamol 2respules

6. Tab. Ecospirin 150 mg po/stat

7. Tab. Atorvas 40 mg po/HS

8. Bp monitoring 2nd hourly 

9. Grbs-6th hourly 

10. I/O charting


Soap notes


21/12/21


Pt is drowsy , but arousable to deep painful stimulus

Gcs - E3V2M4

Temp- 98.7f

Bp- 140/90mmhg

PR - 100bpm

RR- 18cpm

Spo2- 97% at room air

Grbs-120mg/dl

I/0- 1550/1450ml


Rs -bae+

Cvs- s1s2+

P/a- soft , bs+

Cns- pupils  lt eye underwent cataract surgery, Rt eye sluggish reacting to light

Dolls eye- present 

Tone-

             Rt.                 Lt

Ul.          N                   Dec

LL.        Dec.             dec

Power

             Rt.                 Lt

UL.        3/5.              3/5

LL.         2/5.              2/5

Reflexes

            Rt.           Lt

Biceps -               -

Triceps -             -

Supinator-           -

Knee-                   -

Ankle.   -              -

Plantar flexors.    Flexors


A-

Acute ischemic stroke ( lacunar infract in Rt frontal and occipitotemporal lobe)

Chronic infracts in Rt lentiform nucleus 

Denovo HTN

H/0 chronic smoker and alcoholic 


P-

Rt feeds 100ml milk protein followed by 50ml free water 4th hrly

Ivf NS RL @ 75ml/hr

Tab ecosporin 75Mg po od

Tab atorvastatin 20mn po od


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