Acute Hemorrhagic Infarct

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BIKSHAMAIAH


CHIEF COMPLAINTS:
PATIENT WAS BROUGHT TO CASUALITY WITH COMPLAINTS OF DIFFICULTY IN
SWALLOWING AND DROOLING OF SALIVA SINCE YESTERDAY EVENING.

HISTORY OF PRESENT ILLNESS:
PATIENT WAS APPARENTLY NORMAL 2-3 YEARS BACK , HE THEN DEVELPOED WEAKNESS
OF LEFT UPPER LIMB INSIDIOUS IN ONSET AND GRADULLAY PROGRESSIVE OVER 2-3
DAYS.INITIALLY HAD FEVER WHICH WAS FOLLOWED BY WEAKNESS AND APHASIA.APHASIA
AND WEAKNESS THEN IMPROVED OVER 2MONTHS WITH SLURRING OF SPEECH
,CONTINUED MEDICATION.
2MONTHS BACK PATIENT HAD FEVER FOLLOWED BY WEAKNESS OF RIGHT UPPER LIMB
AND APHASIA.
RIGHT UPPER LIMB WEAKNESS IMPROVED BUT APHASIA IS STILL PRESENT.
PATIENT SUDDENLY DEVELOPED DROOLING OF SALIVA SINCE YESTERDAY NIGHT AND
WITH DIFFICULTY IN SWALLOWING ORALLY.
NO H/O LOSS OF CONSIOUSNESS,SHORTNESS OF BREATH,CHEST PAIN.

PAST HISTORY:
K/C/O HYPERTENSION SINCE 10YERAS USING UNKOWN MEDICATION T.TELMA 40MG OD
K/C/O SEIZURES SINCE 10YERAS USING T.EPOTIN 100MG BD LAST EPISODE 45DAYS BACK.
K/C/O CVA SINCE 3YEARS NOT USING MEDICATION SINCE 1MONTH.

PERSONAL HISTORY:
DIET: MIXED 
SLEEP: ADEQUATE
BOWEL AND BLADDER MOVEMENTS: NORMAL
ALCOHOL: REGULAR DRINKER. DRNKS AROUND 100ML / DAY SINCE 30 YEARS
SMOKING: SMOKES CHUTTA 1 PACKET/DAY SINCE 25 YEARS

GENERAL PHYSICAL EXAMINATION:
PATIENT IS CONSIOUS,COHERENT,COPERATIVE
NO SIGNS OF PALLOR, ICTERUS , CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA.
TEMP: AFEBRILE
PR:78BPM
BP:130/70 MMHG
RR: 20 CPM
SPO2: 84% AT RA ; 98% WITH 2 L OF O2.
GRBS:228 MG/DL.

SYSTEMIC EXAMINATION:
CNS: PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE, WELL ORIENTED TO TIME,
PLACE AND PERSON.
GCS- E4V2M6
MEMORY: IMMEDIATE, IMPLICT, LONG TERM CANT BE ELICITED.
CRANIAL NERVE EXAMINATION: CN V,VI,VII,VIII- CANT BE ELICITED
MOTOR SYSTEM: NORMAL
SENSORY SYSTEM: JOINT POSITION, GRAPHYTHYIA, TWO POINT DISCRIMINATION- CANT
BE ELICITED
ROMBERGS: NEGATIVE
CEREBELLAR: NORMAL
GAIT: NORMAL
ENT REFERRAL DONE ON 14.02.24 I/V/O APHASIA, UNABLE TO PROTRUDE TONGUE,
DIFFICULTY IN SWALLOWING.
ADVISED: UPPER GI ENDOSCOPY

Diagnosis
RECURRENT CVA WITH ACUTE INFARCT IN RIGHT FRONTAL AND RIGHT PARIETAL LOBE;
MCS TERRITORY
ACUTE HEMMORHAGE IN ACUTE INFARCT (HEMMORHAGIC TRANSFORMATION)
CHRONIC INFARCT IN BILATERAL FRONTO PARIETAL LOBE OR RIGHT PARIETAL LOBE IN
MCA/ PCA WATER SHED TERRITORY
K/C/O SEIZURES
HYPERTENSION

Investigations
12/2/24
RBS - 96 mg/dl

HEMOGLOBIN-11.2 gm/dl
TOTAL COUNT-6,400
NEUTROPHILS-62%
LYMPHOCYTES-29%
EOSINOPHILS-04%
MONOCYTES-05%
PCV-34.2
MCV-65.3
MCH-21.5
MCHC-32.8
RBC- 5.23 millions/cumm
PLT- 1.57 lakhs/cumm

RFT:
BLOOD UREA-34 mg/dl
SERUM CREATININE-1.2 mg/dl
SODIUM-138 mEq/L
POTASSIUM-4.0 mEq/L
CHLORIDE-99 mEq/L
CALCIUM IONIZED-1.20 mmol/L

SEROLOGY - NEGATIVE

14/2/24
APTT- 30 sec
PT - 15 sec
INR- 1.11

HEMOGLOBIN-11.9 gm/dl
TOTAL COUNT-9,000
NEUTROPHILS-67%
LYMPHOCYTES-23%
EOSINOPHILS-04%
MONOCYTES-06%
PCV-40.4
MCV-64.5
MCH-19.0
MCHC-29.4
RBC- 6.27 millions/cumm
PLT- 1.74 lakhs/cumm

SODIUM-137 mEq/L
POTASSIUM-3.3 mEq/L
CHLORIDE-96 mEq/L
CALCIUM IONIZED-1.17 mmol/L

16/2/24
HEMOGLOBIN-12.0 gm/dl
TOTAL COUNT-7,800
NEUTROPHILS-57%
LYMPHOCYTES-30%
EOSINOPHILS-05%
MONOCYTES-08%
PCV-37.2
MCV-65.3
MCH-21.5
MCHC-32.9
RBC- 5.70 millions/cumm
PLT- 1.74 lakhs/cumm

BLOOD UREA- 49 mg/dl
SERUM CREATININE - 1.6 mg/dl

SODIUM-136 mEq/L
POTASSIUM-4.0 mEq/L
CHLORIDE-99 mEq/L
CALCIUM IONIZED-1.22 mmol/L

18/2/24
HEMOGLOBIN-11.5 gm/dl
TOTAL COUNT-7,200
NEUTROPHILS-55%
LYMPHOCYTES-28%
EOSINOPHILS-06%
MONOCYTES-11%
PCV-33.7
MCV-63.8
MCH-21.8
MCHC-34.1
RBC- 5.28 millions/cumm
PLT- 2.42 lakhs/cumm

BLOOD UREA- 46 mg/dl
SERUM CREATININE - 1.9 mg/dl

SODIUM-137 mEq/L
POTASSIUM-4.6 mEq/L
CHLORIDE-98 mEq/L
CALCIUM IONIZED-1.26 mmol/L


MRI BRAIN PLAIN ON 13/2/24
IMPRESSION :
ACUTE INFRACT IN RIGHT FRONTAL AND RIGHT PARIETAL LOBES - MCA TERRITORY
FOCI OF ACUTE HEMORRHAGE WITHIN THE ACUTE INFRACT.
CHRONIC INFRACT IN BILATERAL FRNTOPARIETAL LOBES WITH A SMALL FOCUS OF
HEMORRHAGE IN FRONTAL LOBE.
CHRONIC INFRACT IN RIGHT PARIETAL LOBE IN MCA/PCA WATERSHED TERITORY.
MRI BRAIN PLAIN (PROVISIONAL)
IMPRESSION:
E/O FEW AREAS OF DIFFUSEION RESTRICTION WITH ADC HYPERINTENSITY ,SWI
BLOOMING.NOTED IN RIGHT FRONTAL,PARIETAL AND OCCIPITAL REGIONS - ACUTE
HEMMORHEGIC INFRACTS.
DIFFUSION RESTRICTION ,ADC HYPERINTENSITY IN RIGHT PERIVENTRICULAR REGION -
LIKELY ACUTE INFRACT.
E/O 8MM AREA OF SWI BLOOMING NOTED IN LEFT FRONTAL REGION - LIKELY BLEED.
FEW AREAS OF DIFFUSION HYPERINTENSITY ,ADC HYPERINTENSITY NOTED IN RIGHT
OCCIPITAL AND FRONTO PARITAL REGION - LIKELY CHRONIC INFRACT.
DIFFUSE CEREBRAL ATROPHY.
CHRONIC SMALL VESSEL ISCHEMIC CHANGES.
ENCEPHALOMALACIC CHANGES IN RIGHT FRONTAL,PARIETAL,TEMPRAL LOBES AND LEFT
PARIETAL LOBES.

CAROTID DOPPLER ON 16-02-24
IMPRESSION :
HIGH BRANCHING OF BILATERAL CAROTID ARTERIES.
ICA,ECA COULDNT BE EVALUATED BECAUSE OF HIGH BRANCHING
16 X 4 MM ATHEROSCLEROTIC PLAUE NOTED IN RIGHT CCA.

Treatment Given(Enter only Generic Name)
INJ.VITCOFOL 2CC SC/OD
RT FEEDS: WATER 50ML 2HOURLY AND MILK PLUS POWDER PROTEIN
TAB.OLKEM TRIO 6.25MG PO/OD
TAB.PHENYTOIN 100MG PO/BD
INJ.THIAMINE 200MG IN 100ML NS IV/BD
TAB.CITICOLINE 500MG PLUS PIRACATEM 400MG PO/OD
TAB.ATORVASTATIN 20MG PO/HS
SPEECH PHYSIOTHERAPY


Advice at Discharge
TAB.OLKEM TRIO 6.25MG PO/OD
TAB.PHENYTOIN 100MG PO/BD
TAB.THIAMINE 100MG PO/BD
TAB.CITICOLINE 500MG PLUS PIRACATEM 400MG PO/OD
TAB.ATORVASTATIN 20MG PO/HS
SPEECH PHYSIOTHERAPY

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