57 year old male with CVA with tracheostomy

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Dr.N.Deepa , Internee

Roll no. 105

I've been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

Date of admission : 24/05/2023

CASE :
57 M came to casualty with c/o generalised  weakness since 1 month ,fever since 1 week,altered sensorium since 3 days.

HOPI:

Since 1 month he has been complaining of generalised weakness. Since 15 days he has been feeling cold(even though it is summer) and has been switching off all the fans in the house. 

He has been suffering with constipation since 10 days. Has not passed stools at all(confirmed by the attender) He did not take any medication for it
He also complained of abdominal distension/bloating due to not passing stools.

Since 1 week he has fever insidious in onset gradually progressive, high grade. Associated with body pains.Not Associated with chills and rigor. Not relieved with medication.Not associated with nausea, vomiting, burning micturition, headache.

Since 3 days -he fell in the washroom two times(on 22/5/1023)and was not able to get up. When his family members found him, he had slurring of speech and altered sensorium.They took him to the Nalgonda government hospital.
There they gave him an enema and his constipation and bloating was relieved immediately.
They also treated him symptomatically. But he was still in altered sensorium and did not cover
They then shifted him to a private hospital as they had contacts there. There they did MRI and found that infarct in the cortical and subcortical regions of occiput. Tracheostomy was done in view of low GCS.











PAST HISTORY:

In 2019 end of the year-  He has felt "weak" .  One fine day he fell down(due to low energy) while cycling and was immediately rushed to the hospital. They told him his cervical nerves got compressed and said he needed surgery. But due to family issues, he didn't get surgery then, and got it done after 2 months( cervical spondylosis surgery). He recovered after 6 months and started walking with support of a stick since then. The doctors then discovered he had problems in the lumbar region as well (4 years back) and needed surgery too, but didn't give consent for that surgery as they told him he would never be able to walk.
H/o htn since 4 years using medication irregularly
N/k/c/ DM, asthma, epilepsy, thyroid, CAD

PERSONAL HISTORY:
Diet-mixed
Appetite - normal
Sleep - adequate
Bowel and bladder - bowel (constipation),bladder normal.
Addiction - drinks toddy occasionally

GENERAL EXAMINATION:
Patient is C/C/C
Moderately build and nourished.
No pallor,icterus,cyanosis,clubbing, lymphadenopathy,pedal edema.






VITALS:
Temp 101F
Bp -130/90 mmhg
Pr -102 bpm
Rr - 20 cpm
Spo2 100% on 4 liters of RA

SYSTEMIC EXAMINATION:

CNS: 
GCS- E4 V (NT) M6
Power - 
         Rt. Lt
UL - 4/5 4/5
LL - 3/5 3/5
TONE 
UL - N. N
LL - N. N
Reflexes
B - 2+. 2+
T - 2+. 2+
S- 2+. 2+
K - 2+. 2+
A - 2+ 2+
Plantar - extension of big toe in both limbs


RS-B/L air entry present 
       NVBS

CVS- S1s2present, no murmurs heard

PA- soft and non tender.

INVESTIGATIONS:










 
 DIAGNOSIS:( updated)

CVA with Acute ischemic stroke (infarct in right occipital lobe) with dyselectrolytemia (resolved)
with type 1 respiratory failure with left sided spontaneous pneumothorax (resolving) with ICD insitu in 5th intercostal space (29/3/23)with surgical emphysema with grade 3 bedsore with k/c/o HTN since 3 yrs.
S/P Tracheostomy (24/5/23)
S/P Cervical spine repair and plating(2020) with  pyrexia under evaluation secondary to ? klebsiella ET secretions?nosocomial infection

TREATMENT:
1.Soft diet
2.IV FLUIDS NS, RL @ 75 ml/hr 
3.Inj.MAGNEX FORTE 1.5g IV BD
4.TAB. CINOD  10mg PO/BD 
5.TAB.MET-XL 25mg PO/OD
6.TAB.PCM 650 mg PO/TID 
7.ET Tube suctioning 2nd hourly
8.Tepid sponging
9.Bedsore dressing daily
10.Position change 2nd hourly
11.Monitor vitals

TEMPERATURE CHARTING: ( updated)





INVESTIGATIONS:( updated)





ENT referral was done i/v/o tracheostomy:
They advised suctioning 2nd hrly 
Deflate and reinflate 2nd hrly

Urology referral i/v/o scrotal swelling :
Advice:- crepitus present 
                 No active intervention needed

Pulmonology referral i/v/o sob :
Diagnosed to have pneumothorax
Needle thoracocentesis was performed followed by ICD was placed


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