General Medicine E-log

55 year old patient with Cerebrovascular accident and pulmonary koch's disease

chief complaint:

A 55 year old male patient was presented to the OPD with complaint of : 

• slurring of speech
• inability to swallow since 4 days

History of presenting illness:

The patient came to the OPD on 30/6/21,  with complaint of slurred speech, inability to swallow solids and liquids (since 4 days) . he has deviation of tongue( towards right) and is unable to walk since 4 days, there is upper and lower limb weakness, and there was froth spillage from right side of mouth.

History of past illness:

The patient was asymptomatic 20 months ago when he was admitted of CVA(old infarct involving inferior aspect of left cerebellar hemisphere and old lacunar infarct in left thalamus are seen in MRI) his mouth was deviated to one side and there was weakness of limbs. he was admitted in a hospital in hyderabad for 1 week, during which he was diagnosed with active pulmonary koch's, for which he was on ATT for 6 months. patient did not stop smoking even after being diagnosed with TB.

the patient has known history of hypertention since 1 year 

Personal History:

Patient is a chronic smoker - since 40 years- 30 beedis/day

h/o regular consumption of alcohol - 90ml/day

patient has aggressive personality

General Examination: 

patient was conscious with slurred speech.

moderately built and moderately nourished.

pallor: absent

icterus: absent

cyanosis : absent

clubbing: absent

edema : absent

lymphadenopathy: absent

VITALS:

BP: 110/70 mmHg

PULSE RATE: 80 bpm

RESPIRATORY RATE: 18

TEMPERATURE: afebrile

SPO2: 96%

Systemic Examination:

CVS:

inspection:

• chest wall is bilaterally symmetrical
• no visible pulsations,engorged veins, scars and sinuses

palpation;

• jvp: normal
• apex beat: felt in 5th intercoastal space in mid clavicular line

auscultation:

• s1 s2 heard
• no murmurs

RESPIRATORY:

• central position of trachea
• bilateral air entry: positive
• normal vesicular breath sounds are heard
• no added sounds are heard

PER ABDOMEN:

• abdomen distended, soft and non tender.
• bowel sounds heard
• no palpable mass or free fluid

CNS;

patient has dysarthria

deviation of mouth to right side, inability to swallow

tone is increased in both upper and lower limbs

tone:

                          R                      L

upper limb        increased        increased

lower limb        increased        increased

reflexes:

                    Right                                  left

B                   2+                                       2+

T                   2+                                        2+

S                   2+                                         2+

K                  -                                             +

A                  +                                            +

P                   Hyperreflexive             hyperreflexive

fasiculations :  present

INVESTIGATIONS:

1. MRI Scan:

• acute infarct involving right temporal and parietal lobes - MCA territory
• old infarct involving inferior aspect of left cerebellar hemisphere
• old lacunar infarct in left thalamus

1. 
   
   
   
   
   
   
   
   

ECG:

CBP, RFT,LFT, LIPID PROFILE:

2D ECHO

DIAGNOSIS:

left sided CVA with acute infarct in MCA territory involving right temporal and parietal lobe 

TREATMENT PLAN:

30/6/2021

    

• ryles tube was inserted for feeding 
• tab Asprin 
• tab clopidogrel
• tab atorvastatin 

1/7/2021

1. RT Feeds wth 100ml milk a2nd hourly and 100 ml water hourly
2.  INJ. PAN 40mg IV/OD
3.  Inj. optineuron 1 amp in 100ml NS/TV/over 30 min
4.  physiotherapy of left upper limb and face
5.  Tab.  Asprin 150 mg PO/OD
6.  tab. clopiodgrel 75 mg RT/OD     
7. tab. atrovas 40mg PO/OD
8.  Inj. mannitol 100ml IV/TID

2/7/2021

1. RT feeds with 100ml milk 2nd hourly and 100ml water hourly
2. inj. pan 40 mg IV/OD
3. inj. Optineuron 1 AMP in 100ml NS/IV over 30 mins
4. physiotherapy of left upper limb and face
5. tab. clopidogrel 75 MG RT/OD 
6. tab. asprin 150 mg RT/OD 
7. tab atorvas 40 mg RT/OD
8. inj. Mannitol 100ml IV/TID 

3/7/2021 

1. RT Feeds wth 100ml milk a2nd hourly and 100 ml water hourly
2.  Inj. optineuron 1 amp in 100ml NS/TV/over 30 mins
3.  physiotherapy of left upper limb and face
4. Tab.  Asprin 150 mg PO/OD
5. .tab. clopiodgrel 75 mg RT/OD
6.   tab. atrovas 40mg PO/OD
7. BP monitoring 4th hourly

ADVICE AT DISCHARGE:

the patient was discharged on 3/7/2021

1. Tab.  Asprin 150 mg PO/OD at 2 pm
2. .tab. clopiodgrel 75 mg RT/OD at 9 pm
3.  tab. atrovas 40mg PO/OD at 9pm 
4. tab zincovit RT/OD
5. physiotherapy of left upper limb

my queries :

• what is the reason for dysarthria and dysphagia in stroke patients?
• what is the reason for increased tone in both the limbs?
• why was there frothy discharge from the patient's mouth?
• how does physiotherapy help in the treatment of this patient?
• how does smoking predispose to CVA?