93y/male ,Aspiration pneumonia and acute ischemic stroke

 

chief complaints-

C/O RIGHT UPPER AND LOWER WEAKNESS SINCE MORNING ON 16/04/24 AND SLURRING

OF SPEECH SINCE MORNING ON 16/04/24

HOPI: PT WAS APPARENTLY ASYMPTOMATIC 1 DAY BACK THEN HE DEVELOPED RIGHT

UPPER LIMB AND L0WER LIMB WEAKNESS SINCE MORNING ON 16/04/24 . SUDDEN ONSET

NOT A/W INVOLUNTARY MOVEMENTS ,NO FROTHING FROM MOUTH, INVOLUNTARY

MICTURITION,INVOLUNTARY DEFECATION

C/O, SLURRING OF SPEECH SINCE MORNING ON 16/04/24 AND DEVIATION OF MOUTH TO

LEFT SIDE

NO H/O FEVER COUGH,COLD, ALLERGIES

NO H/O ABDOMINAL PAIN, NAUSEA, VOMITING,LOOSE STOOLS.

NO H/O CHEST PAIN PALPITATIONS,SOB,SWEATING

NO H/O PEDAL EDEMA,DECREASED URINE OUTPUT

K/C/O HTN SINCE 25 YRS AND IS ON TAB.AMLODIPINE 5 MG+TAB.TELMISARTAN 40

MG+TAB.HYDROCHLORTHIAZIDE 12.5MG OD

K/C/O BRONCHIAL ASTHMA SINCE 25 YRS AND IS ON INHALER FORMONIDE 1 PUFF [SOS]

PAST HISTORY

N/K/C/O TB,DM2,EPILEPSY,CVD,CAD

ON EXAMINATION:

PT IS CONSCIOUS,COHERENT,COOPERATIVE

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA

TEMP: AFEBRILE

BP: 150/90MMHG

PR:102BPM

RR: 18 CPM

CVS: S1,S2+

RS:BAE+WHEEZE +

PA:SOFT, NT

CNS

HIGHER MENTAL FUNCTIONS:

CONSCIOUS  ORIENTED TO TIME , PLACE AND PERSON

SPEECH: DYSARTHRIA+

DELUSIONS/ HALLUCINATIONS NEGATIVE [ BUT IN THE PAST PT USED TO HAVE- 3 YEARS]

TONE: UL INCREASED

      LL: INCREASED

REFLEXES: B 2+ 2+

T - -

S - -

K - -

A - -

P FLEX FLEX

CEREBELLAR SIGNS:

FINGERNOSE IN-COORDINATION ,KNEE- HEEL IN- COORDINATION - NOT BE ELICITED

ORTHOPAEDIC REFEERAL :ON 18/04/24

DIAGNOSIS :DEGENERATIVE JOINT SPACE SCLEROTIC ACETABULUM

GRADE 4 B/L OSTEOARTHRITIS

ADVICE : TAB.DOLO 650MG PO/SOS

TAB.PAN 40MG PO/OD

TAB. JOINTACE-C2 PO/OD

LEFT TKR

DEATH SUMMARY

A 84 YEAR OLD MALE HYPERTENSION SINCE 20 YEARS AND A KNOWN CASE OF

BRONCHIAL ASTHMA SINCE 20 YEARS PRESENTED TO CASUALITY WITH RIGHT UPPER

LIMB AND LOWER LIMB WEAKNESS AND SLURRING OF SPEECH ON 16/04/2024 AROUND 6

PM WITH THESE COMPLAINTS SINCE 7AM . PATIENT ATTENDERS TOOK HIM TO A LOCAL

HOSPITAL WHERE MRS WAS DONE. MRI SHOWED ACUTE INFARCTS IN LEFT BASAL

GANGLIA AND PARIETAL REGIÓN; AGE RELATED ATROPHY AND ISCHAEMIC CHANGES.

PATIENT CAME TO OUR HOSPITAL FOR FURTHER MANAGEMENT. ON EVALUATION HE WAS

DIAGNOSED AS ACUTE ISCHAEMIC STROKE (RIGHT HAEMIPLEGIA SECONDARY TO ACUTE

INFARCT IN LEFT BASAL GANGLIA AND PARIETAL REGION), KNOWN CASE OF

HYPERTENSION SINCE 20 YRS, KNOWN CASE OFBRONCHIAL ASTHMA SINCE 20 YEARS

PATIENT WAS MANAGED CONSERVATIVELY WITH RYLES TUBE FEEDS, MAINTENANCE

FLUIDS, DUAL ANTIPLATELETS, NEBULISATIONS, ANTIHYPERTENSIVES

ORTHOPAEDICION OPINION WAS TAKEN ON 18/4/24 IN VIEW OF LEFT HIP PAIN, LEFT KNEE

PAIN &EXTERNAL ROTATION OF LEFT LEG, ADVISED FOR NSAIDS, TAB. JOINTACE, LEFT

SIDE TOTAL KNEE REPLACEMENT

ON 19/4/24 AT AROUND 6:00 AIN PATIENT HAD DEVELOPED TACHYCARDIA &TACHYPNOEA

PATIENT WAS DOOWRY &ROOM AIR SATURATION 90%. ABG WAS SENT &OXYGEN

SUPPORT WAS STARTED WITH 4 LIT OF OXYGEN, ROOMAIR SATURATION IMPROVEDTO

100% ABG SHOWED PH: 7-33, PCO2:16.5 PO2: 61.1 HCO3:8.6(TYPE I RESPIRATORY

FAILURE). FEVER SPIKE OF 101.4°F PRESENT AND CHEST X RAY AP VIEW BEDSIDE WAS

TAKEN WHICH SHOWED RIGHT UPPER LOBE, MIDDLE LOBE, LOWER LOBE OPACIFICATION(

SECONDARY TO ? ASPIRATIONAL PNEUMONIA

AT AROUND 9:40 AM PATIENT HAD SUDDEN BRADYCARDIA AND OF IN SATURATION WITH

GCS OF E1V1M4, ABSENT PERIPHERAL AND CENTRAL PULSES. ABG WAS SENT, PATIENT

WAS INTUBATED &, CPR WAY INITIATED AS PER ACLS GUIDELINES &CONTINUED FOR 30

MINUTES.

DESPITE ALL THE EFFORTS PATIENT COULDNOT BE REVIVED AND DECLARED DEAD AT

10:26AM,CONFIRMED WITH AN ECG SHOWING FLAT LINE

IMMEDIATE CAUSE OF DEATH : TYPE 1 RESPIRATORY FAILURE SECONDARY TO

ASPIRATION PNEUMONIA

ANTECEDENT CAUSE OFDEATH :

ACUTE ISCHAEMIC STROKE [ RIGHT HEMIPLEGIA SECONDARY TO ACUTE INFARCT IN LEFT

BASAL GANGLIA AND PARIETAL REGION]

KNOWN CASE OF HYPERTENSION SINCE 20 YEARS

KNOWN CASE OF BRONCHIAL ASTHMA SINCE 20 YEARS

Investigation

HEMOGRAM 16/04/24

HEMOGLOBIN 9.2 GM/DL

TLC COUNT 9100CELLS/CUMM

NEUTROPHILS 64 %

LYMPHOCYTES 25%

EOSINOPHILS 04%

MONOCYTES 07%

BASOPHILS 00 %

PCV 26.6 VOL%

MCV 79.2 FL

MCH 27.3PG

MCHC 34.5%

RDW-CV 14.9 %

RDW-SD 44.5FL

RBC COUNT 3.3 MILLIONS/CUMM

PLATELET COUNT 3.1 LAKHS/CU MM

SMEAR,

RBC NORMOCYTIC NORMOCHROMIC

WBC COUNTS ON SMEAR WITHIN NORMAL LIMITS

PLATELETS ADEQUATE

HEMOPARASITES NOT SEEN

IMPRESSION NORMOCYTIC NORMOCHROMIC ANEMIA

COMPLETE URINE EXAMINATION (CUE) 16-04-2024

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Trace

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 3-4

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

RFT 16-04-2024

UREA 21 mg/dl 50-17 mg/dl

CREATININE 1.1 mg/dl 1.7-1.0 mg/dl

URIC ACID 5.6 mmol/L 7.2-3.5 mmol/L

CALCIUM 9.7 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.1 mg/dl 4.5-2.5 mg/dl

SODIUM 140 mmol/L 146-132 mmol/L

POTASSIUM 4.4 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 103 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 16-04-2024

Total Bilurubin 0.50 mg/dl

Direct Bilurubin 0.17 mg/dl

SGOT(AST) 18 IU/L

SGPT(ALT) 16 IU/L

ALKALINE PHOSPHATASE 189 IU/L

TOTAL PROTEINS 5.7 gm/dl

ALBUMIN 3.4 gm/dl

A/G RATIO 1.51

COMPLETE URINE EXAMINATION (CUE) 17-04-2024

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN +++

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 1-2

EPITHELIAL CELLS 0-1

RED BLOOD CELLS plenty

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

Anti HCV Antibodies - RAPID16-04-2024 :PMNon Reactive

HBsAg-RAPID 16-04-2024 : Negative

HIV 1/2 RAPID TEST ON 16/04/2024 :NON REACTIVE

APTT TEST 31SEC

PROTHOMBIN TIME 15 SEC

BLEEDING TIME 2 MIN 30 SEC

CLOTTING TIME 4 MIN 30 SEC

INR 1.11

HB A1C : 6%

RBS: 92 MG/DL

CULTURE REPORT :NO GROWTH AFTER 48 HRS OF AEROBIC

USG ON 16/4/24

IMP-B/L RAISED ECHOGENECITY IN KIDNEYS

BORDERLINE PROSTATOMEGALY

2D ECHO ON 17/4/24:

NO RWMA ,CONC LVH+

TRIVIAL MR+/AR+ MILD TR+, NO PAH

GOOD LV SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

NO PE CLOTS

Treatment Given(Enter only Generic Name)

RYLES TUBE FEEDING 200 ML WITH PROTIEN POWDER 4TH HOURLY 100 ML WATER 2ND

HLY

IV FLUIDS NS RL 5-0 ML/HR

INJ. PIPTAZ 2.25GMS IV TID

INJ. CLINDAMYCIN 600MG IV BD

NEB WITH BUDECOT 12TH HRLY, IPRAVENT 6TH HRLY

ROTA HALER WITH FORMAMIDE 1 PUFF/SOS

TAB. ECOSPRIN 150 MG PO/OD

TAB. CLOPIDOGREL 75MG PO OD

TAB. ROSUVASTATIN 40 MG PO/OD

TAB TELMA AM 40/5 MG PO OD +TAB. AMLODIPINE 5MG

BP MONITORING 4TH HRLY

PHYSIOTHERAPY OF RT UL AND LL

CHANGE POSITION EVERY 2ND HOURLY

ADD CXRAY,MRI,ABG REPORTS

Diagnosis

IMMEDIATE CAUSE OF DEATH : TYPE 1 RESPIRATORY FAILURE SECONDARY TO

ASPIRATION PNEUMONIA

ANTECEDENT CAUSE OFDEATH :

ACUTE ISCHAEMIC STROKE [ RIGHT HEMIPLEGIA SECONDARY TO ACUTE INFARCT IN LEFT

BASAL GANGLIA AND PARIETAL REGION]

KNOWN CASE OF HYPERTENSION SINCE 20 YEARS

KNOWN CASE OF BRONCHIAL ASTHMA SINCE 20 YEARS

LEARNING POINTS--

ELDERLY MALE WITH CLASSICAL PRSENTATION OF ACUTE ISCHEMIC STROKE 

WITH RISK FACTORS OF HYPERTENSION AND SMOKING 

WITH POST STROKE COMPLICATION OF ASPIRATION PNEUMONIA (WITH BACKGROUND H/O BRONCHIAL ASTHMA)WHICH FURTHUR WORSENED OVER DURATION OF STAY IN HOSPITAL LEAD TO THE MORBIDITY IN THIS CASE.