79M With Broca's Aphasia Thrombolyzed With Tenekteplase Pulmonary Fibrosis

03-12-2024

This is an Online E Log Book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

79M while having a meeting with his family on 29th November shouted at them in anger and was unable to talk further along with paralysis of his right limbs! This MRI was done just before his thrombolysis with tenekteplase 15mg as he was brought in 3 hrs. 

PPM 1 - @PPM3 can you or anyone else tell us if this is T1 or DWI by looking at the WW/WL numbers?

PPM 1 - 79M phenotype

PPM 1 - Post tenekteplase a CT head was done. Also there was no clinical improvement.

12-12-2024

PPM 1 - We reviewed this patient of Broca's aphasia thrombolyzed with tenekteplase and also had an old pulmonary fibrosis again today in the OPD.

EMR SUMMARY

Diagnosis

CVA,ACUTE ISCHEMIC STROKE(ACUTE INFARCTS IN LEFT FRONTAL LOBE AND INSULAR CORTEX WITH RIGHT

HEMIPARESIS)

S/P THROMBOLYSIS WITH INJ TMK 15 MG ON 29/11/24

COMMUNITY ACQUIRED PNEUMONIA ? POST INFECTIVE SEQUELAE OF PULMONARY TB

H/O PULMONARY TB 10 YEARS AGO

ASPIRATION PNEUMONIA

DENOVO HYPERTENSION

Case History and Clinical Find

CHIEF COMPLAINTS:

PATIENT WAS BROUGHT TO CASUALTY WITH C/O DEVIATION OF MOUTH TO LEFT SIDE AND SLURRING OF SPEECH SINCE

YESTERDAY MORNING

HOPI:

PATIENT WAS APPARENTLY NORMAL SINCE YESTERDAY MORNING THEN SUDDENLY DEVELOPED DEVIATION OF MOUTH

TO LEFT SIDE AND SLURRING OF SPEECH,DROOLING OF SALIVA PRESENT ,LATER PATIENT DEVELOPED WEAKNESS IN

RIGHT UPPER AND LOWER LIMBS GRADUALLY WITH DIFFICULTY IN GETTING UP FROM SITTING POSITION AND WALKING

ON OWN

INVOLUNTARY MICTURITION PRESENT

C/O ALTERED SENSORIUM SINCE 2-3 HOURS

C/O COUGH WITH SPUTUM SINCE 10 DAYS SUBSIDED NOW

C/O SOB GRADE 2 MMRC

C/O FEVER-LOW GRADE INTERMITTENT ASSOCIATED WITH CHILLS AND RIGOR RELIEVED WITH MEDICATION AND

SUBSIDED NOW

PAST HISTORY:

K/C/O PULMONARY TB 10 YEARS BACK USED ATT FOR 6 MONTHS

NOT A K/C/O DM,HTN,CVA,CAD,EPILEPSY,THYROID DISORDER

NO C/O VOMITING/LOSS OF CONSCIOUSNESS,INVOLUNTARY MOVEMENTS

GENERAL EXAMINATION :

PATIENT IS C/C/C

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY, EDEMABP: 140/90 MMHG

PR: 74 BPM

RR: 22 CPM

SPO2: 98%

GRBS:95 MG/DL

SYSTEMIC EXAMINATION :

CVS: S1S2 +, NO MURMERS

RS: BLAE + NVBS HEARD

P/A: SOFT , NONTENDER, NO ORGANOMEGALY

CNS: NO FND

Investigation

HEMOGRAM (30/11/24)

HAEMOGLOBIN 12.5 gm/dl

TOTAL COUNT 12,400 cells/cumm

NEUTROPHILS 80 %

LYMPHOCYTES 09 %

EOSINOPHILS 03 %

MONOCYTES 08 %

BASOPHILS 00 %

PCV 37.3 vol %

M C V 82.2 fl

M C H 27.5 pg

M C H C 33.5 %

RDW-CV 13.5 %

RDW-SD 41.7 fl

RBC COUNT 4.54 millions/cumm

PLATELET COUNT 2.96 lakhs/cu.mm

SMEAR

RBC Normocytic normochromic

WBC increased in count

PLATELETS Adequate in number and distribution

HEMOPARASITES No hemoparasites seen

IMPRESSION Normocytic normochromic

with leukocytosis.

RFT 30-11-2024 05:10:PM

UREA 25 mg/dl 42-12 mg/dl

CREATININE 1.0 mg/dl 1.3-0.9 mg/dl

URIC ACID 5.8 mmol/L 7.2-3.5 mmol/L

CALCIUM 9.9 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 2.6 mg/dl 4.5-2.5 mg/dl

SODIUM 136 mmol/L 145-136 mmol/L

POTASSIUM 3.7 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 101 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 30-11-2024 05:10:PM

Total Bilurubin 1.45 mg/dl 1-0 mg/dl

Direct Bilurubin 0.27 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 26 IU/L 35-0 IU/L

SGPT(ALT) 21 IU/L 45-0 IU/LALKALINE PHOSPHATASE 134 IU/L 119-56 IU/L

TOTAL PROTEINS 6.5 gm/dl 8.3-6.4 gm/dl

ALBUMIN 3.25 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.00

COMPLETE URINE EXAMINATION (CUE) 30-11-2024 05:10:PM

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

HBsAg-RAPID 30-11-2024 05:10:PM Negative

Anti HCV Antibodies - RAPID 30-11-2024 05:10:PM Non Reactive

RFT 02-12-2024 11:34:AM

UREA 24 mg/dl 42-12 mg/dl

CREATININE 1.0 mg/dl 1.3-0.9 mg/dl

URIC ACID 5.4 mmol/L 7.2-3.5 mmol/L

CALCIUM 9.8 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 2.0 mg/dl 4.5-2.5 mg/dl

SODIUM 139 mmol/L 145-136 mmol/L

POTASSIUM 3.0 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 102 mmol/L 98-107 mmol/L

SERUM ELECTROLYTES (Na, K, C l) 02-12-2024 09:36:PM

SODIUM 137 mmol/L 145-136 mmol/L

POTASSIUM 3.5 mmol/L 5.1-3.5 mmol/L

CHLORIDE 99 mmol/L 98-107 mmol/L

RFT (2/12/24)

UREA 24 mg/dl

CREATININE 1.0 mg/dl

URIC ACID 5.4 mmol/L

CALCIUM 9.8 mg/dl

PHOSPHOROUS 2.0 mg/dl

SODIUM 139 mmol/L

POTASSIUM 3.0 mmol/L

CHLORIDE 102 mmol/L

SERUM ELECTROLYTES (3/12/24)

SODIUM 137 mmol/L

POTASSIUM 3.5 mmol/L

CHLORIDE 99 mmol/L

CALCIUM IONIZED 1.17 mmol/L

HEMOGRAM(3/12/24)

HAEMOGLOBIN 12.7 gm/dl

TOTAL COUNT 10,600 cells/cumm

NEUTROPHILS 78 %

LYMPHOCYTES 14 %

EOSINOPHILS 02 %

MONOCYTES 06 %

BASOPHILS 00 %

PCV 39.0 vol %

M C V 80.5 flM C H 26.2 pg

M C H C 32.6 %

RDW-CV 13.3 %

RDW-SD 42.1 fl

RBC COUNT 4.85 millions/cumm

PLATELET COUNT 3.63 lakhs/cu.mm

SMEAR

RBC Normocytic normochromic

WBC With in normal limits

PLATELETS Adeqaute

HEMOPARASITES No hemoparasites seen

IMPRESSION Normocytic normochromic blood

picture

2D ECHO ON 2/12//24

MILD TR+,PAH,MILD AR+,TRIVIAL MR +(ECCENTRIC TR +)

NO RWMA,NO AS/MS,SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION

NO PE/LV CLOTS

MRI BRAIN ANGIOGRAPHY (OUTSIDE)

FOCAL AREA OF RESTRICTION ON DWI IN LEFT FRONTAL LOBE, LEFT INSULAR CORTEX SUGGESTIVE OF HYPERACUTE

INFARACT

CHANGES IN CEREBRAL ATROPHY

CHRONIC WHITE MATTER ISCHEMIC CHANGES

NO FOCAL STENOTIC LESIONS/OCCLUSIVE LESIONS/OUTPOUCHINGS SEEN IN INTRACRANIAL ARTERIES

CAROTID DOPPLER

FEW TINY CALCIFIED PLAQUES NOTED IN B/L CAROTID BULBS WITH NO SIGNIFICANT STENOSIS /HEMODYNAMIC

CHANGES

CT BRAIN

CHANGES IN CEREBRAL ATROPHY

FOCAL HYPODENSE LESION IN FRONTAL LOBE S/O ACUTE INFARCT

Treatment Given(Enter only Generic Name)

1.RT FEEDS WITH 100ML WATER 2ND HOURLY AND 100 ML MILK 4TH HOURLY

2.IV FLUIDS NS AND DNS 50ML/HOUR

3.INJ.AUGMENTIN 1.2 GM IV/TID4.TAB.AZITHROMYCIN 500MG RT/OD

4.INJ PAN 40 MG IV/OD

5.INJ OPTINUERON 1 AMP IN 100ML NS IV/OD

6.INJ,ATROPINE 2CC SOS IV IF HR < 50 BPM

7.TAB.CINOD 10 MG OD

8.TAB.ROSUVA GOLD 75/75/20 RT/HS

9.NEB WITH BUDECORT AND MUCOMIST 12TH HOURLY

10.PHYSIOTHERAPY OF RIGHT UPPER AND LOWER LIMB

11.CHEST PHYSIOTHERAPY

Advice at Discharge

RT FEEDS WITH 100ML WATER 2ND HOURLY AND 100 ML MILK 4TH HOURLY

TAB.CINOD 10 MG OD

TAB.ROSUVA GOLD 75/75/20 PO/HS

PHYSIOTHERAPY OF RIGHT UPPER AND LOWER LIMB

SPEECH PHYSIOTHERAPY