55 Y OLD MALE WITH ALTERED SENSORIUM SECONDARY TO ? ISCHEMIC STROKE IN RIGHT PONS AND RIGHT superior CEREBELLAR PEDUNCLE WITH DENOVO TYPE 2 DM WITH RIGHT UPPER LOBE CONSOLIDATION ? COLLAPSE

Unit II admission 02/02/2021 
DR. YAMINI ( INTERN) 
DR. AMULYA ( INTERN) 
DR. SURYA PRADEEP ( INTERN ) 
DR. ASHA KIRAN ( INTERN)
DR. JAYANTH ( INTERN) 
DR. VAMSHI ( INTERN)
DR. ISMAIL  (INTERN)
DR. PRADEEP ( PG 1st YEAR)
DR. NIKITHA ( PG 2nd YEAR)
DR. SUFIYA ( PG 3rd YEAR) 
DR. SATISH ( PG 3rd YEAR)
Faculty : DR. VIJAYALAXMI
55 year old male who is a farmer came to the casualty with C/O 
1. Low grade fever since 2days 
2. Stomach pain with decreased    
     appetite since 2days 
3. Sudden loss of speech since 
    1pm today with 
    unresponsiveness to painful  
    stimuli since 9pm 
4. Weakness of left lower limb 
    since 1pm 

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2days back when he developed low grade fever with no diurnal variation, decreased appetite since 2days for which he was evaluated in hospital near by and treated with K+ supplementation, tramadol and discharged. Stomach pain which decreased on medication.
He had headache the following day for a brief period of 1hour which spontaneously resolved followed by sudden onset of loss of speech and inability to move left lower limb since 1pm. No deviation of mouth, LOC, seizures. Patient was coherent , responding with gestures with sudden deterioration since 9pm today.

PAST HISTORY:
No h/o similar complaints in the past.
K/c/o DM-II since 10days not on medication.
K/c/o periarthritis of right shoulder joint (Under medication 3 months back).
Use of NSAIDs since 3months 
Not k/c/o HTN,CAD,CVA,TB, epilepsy.
PERSONAL HISTORY:
K/c/o smoker (1bidi pack daily for 30years, stopped 10years back)
K/c/o alcoholic, 2times/week since 20years stopped 6months back.
Bowel movements are regular.
GENERAL EXAMINATION 
No pallor, icterus, cyanosis, clubbing, pedal edema, lymphadenopathy.
Patient is mildly dehydrated 
Temp-102.4 F 
PR-104 bpm 
RR- 20cpm 
BP- 130/90mmhg 
SpO2- 99% at RA 
GRBS-93mg% 
Q
CNS EXAMINATION 
Stuporous 
Speech-No response 
GCS-E1V1M2 
Respiration pattern- Normal 
Pupils- Pinpoint b/l unresponsive to light.
Corneal- Absent 
Dolls eye- Absent
Reflexes:    Right        Left 
Biceps          -                - 
Triceps         -                - 
Supinator     -                - 
Knee              -                - 
Ankle             -                - 
Plantar- B/L Extensor 
Gag reflex- Couldn't elicit
Cerebral signs not elicited 
RS- BAE + 
CVS-S1 S2 + 
P/A- soft

Prov. Diagnosis- 
Altered sensorium secondary to 
?Ischemic stroke in right PONS and right superior cerebellar peduncle 
With ? Denovo DM-II with Right upper lobe consolidation ?collapse 

TREATMENT-
DAY 1 
1. Temperature hourly, tepid sponging continuously.
2.Propped up position.
3.RT feed 100ml water hourly and 50ml milk 2nd hourly 
4.INJ NEOMOL 1gm/IV/after informing PG.
5.Change position frequently.
6.GRBS 4th hourly.
7.BP/PR hourly 
8.strict I/O charting

Day 2 
 1. Propped  up position 
2. Air/ water bed 
3. Change position frequently 
4. Et SUCTION 2 ND HOURLY 
5 RT FEEDS  100 ML WATER HOURLY 
                       500 ML MILK 2 ND HOURLY 
6  INJ PANTOP 40 MG /IV/ OD 
7  INJ AGUMENTIN 1.25 GM /IV /TID 
8   INJ MANITOL 100 ML IV /TID 
9   NEB WITH  2 QMP  SALBUTAMOL  8TH  H0URLY , BUDECOT  12 TH HOURLY
10   INJ NEOMOL 1GM / IV / TID AFTER INFORMING   PG 
11  IVF NS ( 0.9 % @ 75 ML / HR) 
12  TAB ASPIRIN  75 MG / RT/OD 
13 TAB ATORVAS 20 MG RT /HS 
14  TEMP H0URLY 
15  ABG 6 TH HOURLY 
16  STRICT I/O  CHARTING 
17  BP PULSE  HOURLY 
18  GRBS  4TH HOURLY 
19 REFRESH   TEARS   00  - 00  - 00  -00
20  PHYSIOTHERAPY   OF LEFT   LL
21  ICE PACKS AND TEPID SPONGING 
   


Day 3
 1. Propped  up position 
2. Air/ water bed 
3. Change position frequently 
5 RT FEEDS  100 ML WATER HOURLY 
                       50 ML MILK 2 ND HOURLY 
6  INJ PANTOP 40 MG /IV/ OD 
7  INJ AGUMENTIN 1.25 GM /IV /TID 
8   INJ MANITOL 100 ML IV /TID 
9   NEB WITH  2 QMP  SALBUTAMOL  8TH  H0URLY , BUDECOT  12 TH HOURLY
10   INJ NEOMOL 1GM / IV / TID AFTER INFORMING   PG 
11  IVF NS ( 0.9 %  NACL @ 75 ML / HR) 
12  TAB ASPIRIN  75 MG / RT/OD 
13 TAB ATORVAS 20 MG RT /HS 
14  TEMP H0URLY 
15  CHANGE   POSITION   FREQUENTLY 
16  STRICT I/O  CHARTING 
17  BP PULSE  HOURLY 
18  GRBS  4TH HOURLY 
19 REFRESH   TEARS   00  - 00  - 00  -00
20  PHYSIOTHERAPY   OF LEFT   LL
21  TEPID SPONGING

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