48M with Left Hemiparesis

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N. RAVI

CHIEF COMPLAINTS:
A 48 YEAR OLD MALE CAME TO CASUALITY WITH COMPLAINTS OF DIFFICULTY IN
SWALLOWING
INCREASED FREQUENCY OF URINE
UNILATERAL WEAKNESS OF LEFT SIDE UPPER AND LOWER LIMBS SINCE 1 WEEK

HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ALRIGHT 1 WEEK BACK AND THEN HE DEVELOPED DIFFICULTY
IN SWALLOWING SINCE 1 WEEK ;SOLIDS GREATER THAN LIQUIDS
INCREASED FREQUENCY OF URINE SINCE 1 WEEK ;SENSES ABSENT;FOUL SMELLING .
NO H/O FEVER,COLD,COUGH. NO H/O BURNING MICTURITION.NO H/O CHEST PAIN
,PALPITATIONS,SWEATING,SOB

PAST HISTORY:
K/C/O CVA IN 2019 -TAB.CARDIOSTATIN -10 GOLD
K/C/O EPILEPSY IN 2019 -TAB.LEVITERACETAM 500 MG PO /OD
K/C/O DM TYPE 2 SINCE 12 YEARS ON INJ MIXTARD AND TABLET TENEGLIPTIN 20 MG
PO/OD

PERSONAL HISTORY:
DIET: MIXED 
SLEEP: ADEQUATE
BOWEL MOVEMENTS: NORMAL
BLADDER MOVEMENTS: INCREASED FREQUENCY OF MICTURITION SINCE 1 WEEK
ALCOHOL: REGULAR DRINKER SINCE 20 YEARS. STOPPED 6 YEARS AGO.
SMOKING: NO


GENERAL EXAMINATION:
ON EXAMINATION PT IS C/C/C
NO PALLOR,ICTERUS ,CYANOSIS,CLUBBING ,LYMPHADENOPATHY
PR:92 BPM
RR:18 CPM
BP:140/70 MMHG
SPO2 : 97% @ RA
TEMP:98.2 F
GRBS:379

SYSTEMIC EXAMINATION
CVS: S1 S2 +NO MURMURS
RS:BAE+ NVBS
P/A SOFT NON TENDER,NO ORGANOMEGALY
CNS:NFND

ENT REFERRAL DONE ON 29/2 /24 I/V/O DIFFICULTY IN SWALLOWING
ADVISED UPPER GI ENDOSCOPY FOR FURTHER EVALUATION.
UROLOGY REFERRAL DONE ON 29/2 /24 I/V/O URINARY INCONTINENCE AND FOUL
SMELLING URINE AND ADVISED
1.SYP.CREMAFFIN 15 ML HS
2.TAB. SOLITEN 5 MG X3 WEEKS OD
3.CST AS PER CHART

NEUROLOGY REFERRAL DONE I/V/O ODYNOPHAGIA,INCREASED WEAKNESS OF UL AND LL
AND BOWEL AND BLADDER INCONTINENCE AND ADVISED MRI BRAIN PLAIN

PSYCHIATRY REFERRAL DONE ON 4/3/24 I/V/O IRRITABLE BEHAVIOUR SINCE 3/3/24 NIGHT
IMPRESSION : ADJUSTEMT ISSUES WITH FAMILY
ADVISED
TAB LORAZEPAM 2MG PO/SOS
PATIENT AND ATTENDER PSYCHO EDUCATED

Diagnosis
ACUTE KIDNEY INJURY SECONDARY TO PYELONEPHRITIS
IRON DEFICIENCY ANEMIA
DIABETIC KETOSIS [RESOLVED]
RECURRENT CVA [LT HEMIPLEGIA]
OVERACTIVE BLADDER
H/O CVA[LEFT HEMIPARESIS] 6 YEARS AGO
K/C/O EPILEPSY SINCE 6 YEARS
K/C/O DM 2 SINCE 10 YEARS

COURSE IN THE HOSPITAL
A 48 YR OLD MALE KNOWN DIABETIC WITH HISTORY OF LEFT HEMIPARESIS SINCE 6 YEARS
,K/C/O EPILEPSY SINCE 6 YEARS ADMITTED I/V/O INCREASE WEAKNESS OF LEFT UPPER
LIMB AND LOWER LIMB,URINARY INCONTINENCE AND FECAL INCONTINENCE ,PATIENT
WAS EVALUATED FEVER SPIKES WERE PRESENT SINCE DAY 1 OF ADMISSIONAND RENAL
PARAMETERS WERE DERRANGED,USG ABDOMEN AND PELVIS SHOWED B/L BULKY KIDNEYS WITH ALTERED ECHOTEXTURE,UNCONTROLLED SUGARS AND URINE FOR KETONE BODIES POSITIVE AND DIAGNOSED AS AKI SECONDARY TO ACUTE
PYELONEPHRITIS,DIABETIC KETOSIS,RECURRENT CVA [LEFT HEMIPLEGIA] AND STARTED
ON IV FLUIDS AND INSULIN INFUSION.ONCE SUGARS WERE UNDER CONTROL AND URINE
FOR KETONE BODIES NEGATIVE INSULIN INFUSION WAS STOPPED AND CONVERTED TO S/C INSULIN,INJ LEVOFLOXACIN 200MG GIVEN FOR 3 DAYS .FEVER SPIKES SUBSIDED
,TOTAL COUNTS WERE IN DECREASING TRENDS.TAB CIPROFLOXACIN 500MG STARTED
.NEPHROLOGY OPINION WAS TAKEN AND ADVISED TO CONTINUE SAME
TREATMENT.UROLOGY OPINION WAS TAKEN I/V/O URINARY INCONTINENCE DIAGNOSED AS OVERACTIVE BLADDER AND TREATMENT WAS GIVEN ACCORDINGLY .INJ IRON SUCROSE WAS GIVEN I/V/O IRON DEFICIENCY ANEMIA.PATIENT VITALS ARE STABLE AT THE TIME OF DISCHARGE, PSYCHIATRY REFFERAL WAS DONE I/V/O IRRITABLE BEHAVIOUR COUNSELLED PATIENT AND ATTENDERS .
PSYCHIATRY REFERRAL WAS DONE I/V/O IRRITABLE BEHAVIOUR
COUNSELLED PATIENT AND PATIENT ATTENDERS.

Investigation
POST LUNCH BLOOD SUGAR 29-02-2024 02:48:PM 420mg/dl 140-0 mg/dl
BLOOD UREA29-02-2024 109 mg/dl
SERUM CREATININE29-02-2024 3.8 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 29-
02-2024 
SODIUM 137 mEq/L
POTASSIUM 4.5 mEq/L
CHLORIDE101 mEq/L

LIVER FUNCTION TEST (LFT) 29-02-2024 02:48:PM
Total Bilurubin 1.62 mg/dl
Direct Bilurubin0.27 mg/d
SGOT(AST)10 IU/L
SGPT(ALT)10 IU/L
ALKALINE PHOSPHATASE191 IU/L
PROTEINS6.5 gm/d
ALBUMIN2.9 gm/dl
A/G RATIO0.82

COMPLETE URINE EXAMINATION (CUE) 29-02-2024 02:48:PM 
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY1.010
ALBUMINNil
SUGAR+++
BILE SALTSNil
BILE PIGMENTSNil
PUS CELLS2-3
EPITHELIAL CELLS2-3
RED BLOOD CELLSNil
CRYSTALSNil
CASTSNil
AMORPHOUS DEPOSITSAbsent
OTHERSNil
HBsAg-RAPID29- 02-2024 02:48:PMNegative 
Anti HCV Antibodies - RAPID29-02-2024 Non Reactive 
POST LUNCH BLOOD SUGAR29-02-2024 174 mg/dl
BLOOD UREA29-02-2024 106 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 29-02-2024 
SODIUM140 mEq/L
POTASSIUM4.1 mEq/L
CHLORIDE104 mEq/L
SERUM CREATININE29-02-2024 3.7 mg/dl
ABG 01-03-2024
PH 7.446
PCO2 24.4
PO2 133
HCO3 16.6
St.HCO3 19.4
BEB-6.1
BEecf-6.8
TCO234.7
O2 Sat97.9
O2 Count 12.5


MRI BRAIN PLAIN IMPRESSION:
MULTIPLE ACUTE INFARCTS IN RIGHT PARASAGITTAL
REGION AND RIGHT PARIETO-OCCIPITAL REGION IN A WATERSHED DISTRIBUTION
OLD INFARCT WITH ENCEPHALAMALACIC CHANGES IN SURROUNDING GLIOSIS IN RIGHT
FRONTAL AND TERRITORIAL DISTRIBUTION OF ACA
ATROPHY OF LEFT SIDED CEREBRAL PEDUNCLE OF MID BRAIN -?CAUSE
HEMOGRAM : 29/2/24
HB :9.8
TLC :14,OOO
N/L/E/M/B:88/6/6/7/0
PCV 28.7
MCV 74.9
MCH25.6
MCHC 34.1
RDW CV 13.4
RDW SD 37.9
RBC COUNT 3.83
PLATELET COUNT : 2.9
HEMOGRAM : 2/3/24
HB :8.0
TLC :16,OOO
N/L/E/M/B:88/4/1/7/0
PCV 24.4
MCV 76.0
MCH 25.0
MCHC 33.0
RBC COUNT 3.22
PLATELET COUNT : 2.24
2/3/24
TOTAL CHOLESTROL 102
TRIGLYCERIDES 142
HDL 30
LDL 74
VLDL 28
URINE FOR KETONE BODIES -VE
3/3/24
HEMOGRAM : 4/3/24
HB :7.8
TLC :15,OOO
N/L/E/M/B:86/5/1/8/0
RBC COUNT 3.4
PLATELET COUNT : 1.97
CUE :ALBUMIN +
BACTERIA +
PUS CELLS PLENTY
SERUM CREATININE 4.4
BLOOD UREA - 12
4/3/24
CUE PUS CELLS 2-4
EPITHELIAL CELLS 2-3
BLOOD UREA : 118
SERUM CREATININE 4.3
SODIUM 140
POTASSIUM 4.7
CALCIUM 102
6/2/24
BLOOD UREA 92
SERUM CREATININE 4.4
2D ECHO
IMPRESSION : EF 65 %
TRIVIAL TR +,AR+, NO MR
NO RWMA, NO AS/MS
SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLYIC DYSFUNCTION, NO PAH OR PE
USG ABDOMEN : 29/2/24
IMPRESSION :
SLIGHTLY BULKY , ALTERED ECHOTEXTURE OF B/L KIDNEYS
WITH NO PERINEPHRIC FLUID .
IRREGULAR THICKENING OF URINARY BLADDER WALL NOTED MEASURING 5MM WITH
INTERNAL ECHOES
REVIEW USG DONE ON 5/3/24 I/V/O RPD CHANGES, PYELONEPHRITIS
IMPRESSION :
RT KIDNEY - 10.7 X 5.6 CM , LT KIDNEY - 10.8 X 7.1 CM BOTH KIDNEYS BULKY, ALTERED
ECHOTEXTURE,NO PERINEPHRIC FLUID,SLIGHT INTERNAL ECHOES IN LEFT RENAL PELVIS
CAROTID DOPPLER :
IMPRESSION :
E/O 7 X 1 MM PLAQUE NOTED IN RIGHT CCA ,5 X 1 MM PLAQUE AT THE BIFURCATION OF
RIGHT CCA
9 X 1 MM PLAQUE NOTED IN RIGHT ECA ,2 X 1 MM CALCIFIED PLAQUE IN LEFT ICA
ICA/ CCA (PSV)RATIO IS <2 BILATERALLY (NORMAL)

Treatment Given(Enter only Generic Name)
1.IVF NS @75 ML/HR
2.INJ. PAN 40 MG IV OD
3.INJ NEOMOL 1G IV IF TEMP >101 F
4.INJ HAI S/C TID ACCORDING TO GRBS
5.TAB. CARDIOROSTIN GOLD-10 PO HS
6.TAB. CITICHOLINE P PO OD
7. TAB. DOLO 650 MG PO SOS
8.TAB. SOLITEN 5 MG PO OD
9.TAB. LEVIPIL 500 MG PO OD
10. SYP CREMAFFIN 15 ML PO HS
11. PROTEIN POWDER 2 SCOOPS IN 1 GLASS OF WATER BD
12. INJ .LEVOFLOXACIN 200 MG IV BD

Advice at Discharge
1. TAB. CIPROFLOXACIN 500 MG PO OD x 6 DAYS
2. TAB . CINOD 10 MG PO OD CONTINUE
3.TAB. CARDIOROSTIN 10 GOLD PO HS CONTINUE
4. TAB. CITICHOLINE PO OD CONTINUE
5. TAB . SOLITEN 5MG PO OD 2 WEEKS
6. TAB .LEVIPIL 500 MG PO OD CONTINUE
7. TAB . OROFER XT PO OD 3 MONTHS
8. TAB NODOSIS 500 MG PO OD 2 WEEKS
9.TAB.LORAZEPAM 2MG SOS( WHEN IRRITABLE &RESTLESS &LACK OF SLEEP)
10.TAB.LASIX 20MG PO BD X 1 WEEK
11.INJ.HUMAN ACTRAPID INSULIN 4U/SC/TID(4U-4U-4U) X 1 WEEK
12. SYP. CREMAFFIN 15 ML PO HS
13. PLENTY OF ORAL FLUIDS
14. REGULAR PHYSIOTHERAPY FOR LEFT UPPER LIMB AND LOWER LIMB 15. STRICT
DIABETIC DIET

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