78y-came with loss of speech

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 This is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts to solve those patients' clinical problems with collective current best evidence-based information.


This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome.

med case:

Who came c/o loss of speech for one month.

the patient was apparently asymptomatic till one month ago, then she was found in an unconscious state on the roadside then she was noticed by the attendees and was taken to the local hospital and treated by a local doctor for 3 days and then taken to an outside hospital, where CT brain was done=>Ischemic stroke was diagnosed, weakness and loss of speech => after 3-4 days they were transferred to other hospital (financial constraints)=>stayed there for 10 days and her power recovered and speech has improved and was discharged => after  10 days patient power deteriorated with decrease speech and was brought to our hospital.


PAST HISTORY:- 

Known case of HTN AND ON AMLODIPINE 5 mg 

Not a known case of DM; CAD; Thyroid; TB; or asthma.


PERSONAL HISTORY:-


Diet - mixed 

Appetite- normal

Sleep - adequate 

Micturition:- Normal 

Addictions :- smoking occasional 


Allergic history:- No history of any kind of allergies to food/drugs


Family history:- no significant family history 


GENERAL EXAMINATION:- 











NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ; LYMPHADENOPATHY ; EDEMA


TEMPERATURE:- AFEBRILE

PR:98 bpm ; irregularly irregular 

BP:100/60 mmHg @ 4ml/hr noradrenaline 

RR:28 cpm

GRBS:- 109 mg/dl


SYSTEMIC EXAMINATION:- 



CVS:S1 S2+,NO MURMURS


RS:BAE+ ; NVBS ; B/L BASAL CREPTS


P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY 


CNS:- 


Tone 

       Right                     Left 

U.L   N.                           Increased

L.L.   N.                           Increased 


Power 

        Right   Left 

U.L    3/5.    3/5

L.L.    3/5.    3/5


Reflexes 

         Right     left 

B        ++.         ++

T.       ++.          ++

S.       -              - 

K.        ++.       ++ 

A.              -          -


PLANTAR:- flexor.    Extensor 




ALTERED SENSORIUM 2 to  CHRONIC ISCHEMIC  STROKE AT LEFT MCA TERRITORY  PERSISTENT, NON-VALVULAR ATRIAL FIBRILLATION WITH FVR  2 to CAD HEART FAILURE WITY PRESERVED EJECTION FRACTION 2' to CAD with HYPOKALEMIA  (Resolving)  WITH CARDIOGENIC SHOCK WITH HTN SINCE 4 years 



MANAGEMENT:- 

1. RT FEEDS - 4 Th hourly —- water / 4 Th hourly Milk 

2. INJ NORADRENALINE @4ml/hr IV INFUSION INCREASE OR DECREASE ACCORDING TO MAP ; maintain MAP > 65 mmHg 

3. INJ HEPARIN IV/QID 

4. TAB ECOSPIRIN AV (75/20) RT /HS 

5. INJ AMIODARONE 6mg/ml @ 6.3 ml/hr 

6. SYP POTKLOR 15 ml in one glass of water 

7. Monitor vitals hourly.


INVESTIGATIONS:

SEROLOGY - NEGATIVE

HAEMOGLOBIN. 12.2


TOTAL COUNT 6900


NEUTROPHILS 38

LYMPHOCYTES 49 

EOSINOPHILS 05 

MONOCYTES 08 

BASOPHILS 00

PCV. 37.8 

 

MCV 88.1 


MCH 28.4 


MCHC 32.3 


RDW-CV

12.6

RDW-SD

41.5

RBC COUNT

4.29 

PLATELET COUNT 3



RFT:- 


Urea:- 37 

Creatinine:-0.9

Sodium:- 140

Potassium:-4.2

Chloride:- 102 


Total Bilirubin 1.17

Direct Bilirubin 0.86

ALKALINE PHOSPHATE  150

TOTAL PROTEINS:- 7.7

CUE-

ALBUMIN-1+

SUGARS: NILL

PUS CELLS: 2-4

EPITHELIAL CELLS: 2-3

BLOOD GROUP: O- NEGATIVE

ECG - 





Questions asked in today’s osce:- 


Efficacy of amiodarone? In atrial fibrillation 


In amiodarone-treated patients (N = 1,107), freedom from recurrent atrial fibrillation was 84% and 45% at 1 and 5 years, respectively, with no differences according to left ventricular function (P = 0.8754).


Amiodarone's efficacy in maintaining sinus rhythm and reducing the burden of atrial fibrillation is similar in the presence or absence of severe left ventricular dysfunction. Rhythm control with amiodarone is associated with comparable hospitalization and mortality rates to rate control in patients with and without left ventricular dysfunction.


https://pubmed.ncbi.nlm.nih.gov/25181386/#:~:text=In%20amiodarone%2Dtreated%20patients%20(N,function%20(P%20

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