19-03-2025
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 PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[19-03-2025 16.16] PPM 1: Afternoon session:
38M with neck pains since mid 2023 and progressed to headache since last 6 months and weakness of
pincer grip since 3 months and was on acupuncture therapy with 25% subjective improvement!
Cervical MRI since 2023 showed features suggestive of compressive myelopathy since then that
remained same on repeated MRI.
Since two days developed sudden involuntary movement of all four limbs and left hemiparesis along
with vomiting and retching.
On examination,
Left eye ptosis with left eye abducted at resting position with miosis (Horners syn)
Lower cranial nerves 9,10 11 affected with reduced palatal movement and inability to cough just
producing a bovine sound at all cough attempts (video attached) 👇
Left motor hemi paresis
https://youtu.be/U2kyrU9I5xk?si=lCTtT6EiHnI0viFq
{19-03-2025 16.24] PPM 1: Clinico radiology correlation
[24-03-2025 19:06] PPM 1: Thanks @~PA aap log abhi kahan hain? Patient kaisa hai?
EMR summary:
Age/Gender : 40 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 17/03/2025 07:18 PM
Diagnosis
-CVA -AIS ACUTE INFRACT IN LEFT LATERAL MEDULLARY AREA SECONDARY TO ?PRIMARY POLYCYTHEMIA VERA
- SMALL MULTIPLE ACUTE INFARCTS IN LEFT FRONTO PARIETAL AND B/L OCCIPITAL WITH LEFT HEMIPARESIS WITH RIGHT UMN FACIAL PALSY
- DENOVO HYPERTENSION
Case History and Clinical Findings
C/O VOMITINGS SINCE AFTERNOON
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC TILL AFTERNOON , THEN HE DEVELOPED VOMITINGS, INSIDIOUS ONSET, GRADUALLY PROGRESSIVE (6 EPISODES) AND CONTAINS FOOD AND WATER , NON-BILIOUS , NON-PROJECTILE, NON- BLOOD STAINED AND ASSOCIATED WITH NASUEA .
PATIENT DEVELOPED LEFT UPPER LIMB WEAKNESS ASSOCIATED, WITH SLURRING OF SPEECH, DEVIATION OF MOUTH TOWARDS LEFT ,,DROOPING OF LEFT EYE DOWNWARDS AND OUTWARDS.
NO H/O PAIN ABDOMEN, BREATHLESSNESS
NO H/O CHEST PAIN, PALPITATIONS, ORTHOPNEA, PND, PEDAL EDEMA, COUGHY, COLD, LOOSE STOOLS
PAST HISTORY:
PAST HISTORY:
N/K/C/O SEIZURE LIKE ACTIVITY N/K/C/O DM, HTN,CAD,CVA,TB,ASTHMA. PERSONAL HISTORY:
APPETITE - NORMAL BOWELS- REGULAR BLADDER-NORMAL SLEEP- ADEQUATE NO ALLERGIES ADDICTIONS -NIL
GENERAL EXAMINATION:PATIENT IS C/C/C TEMPERATURE - AFEBRILE
BP - 150/100 MMHG PR - 96 BPM
RR - 22CPM
SPO2 - 98 % AT RA GRBS: 145MG/DL
CVS - S1 S2 HEARD, NO MURMURS RS - BAE PRESENT, NVBS HEARD
PER ABDOMEN -SOFT,NO TENDERNESS .
SOFT, NO HEPATOMEGALY, NO SPLENOMEGALY CNS -
TONE RIGHT LEFT UL N N
LL N N
POWER RIGHT LEFT UL 5/5 5/5
LL 5/5 5/5
REFLEXES
B +3 - T+2 - S+ - K +3 - A+ -
PLANTAR MUTE MUTE GLASGOW SCALE -E4V5M6
OPHTHALMOLOGY REFFERAL WAS DONE ON 19/3/25 IMPRESSION : NORMAL FUNDUS STUDY
Investigation
ABG 17-03-2025 09:02:PM
PH 7.29PCO2 33.4PO2 96.0HCO3 15.6St.HCO3 17.0BEB -9.6BEecf -
9.7TCO2 29.9O2 Sat 96.9O2 Count 24.9
SERUM ELECTROLYTES (Na, K, C l) 17-03-2025 09:18:PM
SODIUM 140 mmol/L 145-136
mmol/L
POTASSIUM 5.2 mmol/L 5.1-3.5 mmol/LCHLORIDE 100 mmol/L 98-107 mmol/LHBsAg- RAPID 17-03-2025 10:59:PM Negative
Anti HCV Antibodies - RAPID 17-03-2025 10:59:PM Non Reactive RFT 17-03-2025 11:21:PM UREA
12 mg/dl 42-12 mg/dl CREATININE 1.0 mg/dl 1.3-0.9 mg/dl URIC ACID 6.7 mmol/L 7.2-3.5
mmol/LCALCIUM 10.2 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 4.4 mg/dl 4.5-2.5 mg/dl SODIUM 140
mmol/L 145-136 mmol/LPOTASSIUM 5.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 103 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 17-03-2025 11:21:PMTotal Bilurubin 1.75 mg/dl 1-0 mg/dl Direct Bilurubin 0.45 mg/dl 0.2-0.0 mg/dl SGOT(AST) 27 IU/L 35-0 IU/LSGPT(ALT) 27 IU/L 45-0
IU/LALKALINE PHOSPHATASE 158 IU/L 280-53 IU/LTOTAL PROTEINS 7.8 gm/dl 8.3-6.4
gm/dl ALBUMIN 4.96 gm/dl 5.2-3.5 gm/dl A/G RATIO 1.75
COMPLETE BLOOD PICTURE (CBP) 17-03-2025 11:21:PM HAEMOGLOBIN 18.0 gm/dl 17.0-13.0
gm/dl TOTAL COUNT 28000 cells/cumm 10000-4000 cells/cumm NEUTROPHILS 92 % 80-40
%LYMPHOCYTES 04 % 40-20 %EOSINOPHILS 00 % 6-1 %MONOCYTES 04 % 10-2
%BASOPHILS 00 % 2-0 %PLATELET COUNT 5.5SMEAR Normocytic normochromic blood picture with neutrophilic leucocytosis ADVICE: erythropoitein level due to increased HB levels
HEMOGRAM 18/3/25
HAEMOGLOBIN 18.0 gm/dl TOTAL COUNT 28,000 cells/cumm NEUTROPHILS 92 % LYMPHOCYTES 04 %EOSINOPHILS 00 % MONOCYTES 04 % BASOPHILS 00 % M C V 79.7 fl M C H 29.0 pg M C H C 36.4 % RDW-CV 15.4 % RBC COUNT 6.21 millions/cumm PLATELET COUNT
5.5 lakhs/cumm RBC Normocytic normochromic WBC increased counts on smear with absolute neutrophilia PLATELETS increased counts on smear Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic blood picture with neutrophilic leucocytosis ADVICE: erythropoitein level due toincreased Hb levels
FASTING LIPID PROFILE (18/3/25)
Total Cholesterol 207 mg/dl High : >239Triglycerides 286 mg/dl HDL Cholesterol 55 mg/dl LDL Cholesterol 120 mg/dl. VLDL * 57 mg/dl 12-40 mg/dl
COMPLETE URINE EXAMINATION (CUE) 18-03-2025 12:14:AM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP. GRAVITY 1.010ALBUMIN +++SUGAR +BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil SERUM ELECTROLYTES (Na, K, C l) 18-03-2025 03:03:PM SODIUM 141 mmol/L 145-136
mmol/LPOTASSIUM 4.2 mmol/L 5.1-3.5 mmol/LCHLORIDE 101 mmol/L 98-107 mmol/L
RFT 18-03-2025 11:34:PMUREA 32 mg/dl 42-12 mg/dl CREATININE 1.0 mg/dl 1.3-0.9 mg/dl URIC
ACID 5.6 mmol/L 7.2-3.5 mmol/LCALCIUM 10.2 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 3.6 mg/dl 4.5-
2.5 mg/dl SODIUM 134 mmol/L 145-136 mmol/LPOTASSIUM 4.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
106 mmol/L 98-107 mmol/LSERUM ELECTROLYTES (Na, K, C l) 18-03-2025 11:34:PMSODIUM
134 mmol/L 145-136 mmol/LPOTASSIUM 4.4 mmol/L 5.1-3.5 mmol/LCHLORIDE 106 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 18-03-2025 11:34:PMTotal Bilurubin 2.58 mg/dl 1-0 mg/dl Direct Bilurubin 0.48 mg/dl 0.2-0.0 mg/dl SGOT(AST) 16 IU/L 35-0 IU/LSGPT(ALT) 19 IU/L 45-0
IU/LALKALINE PHOSPHATASE 162 IU/L 280-53 IU/LTOTAL PROTEINS 7.1 gm/dl 8.3-6.4
gm/dl ALBUMIN 4.46 gm/dl 5.2-3.5 gm/dl A/G RATIO 1.69
COMPLETE URINE EXAMINATION (CUE) 19-03-2025 11:29:AM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN ++SUGAR NIL SALTS Nil BILE PIGMENTS Nil
PUS CELLS 3-4
EPITHELIAL CELLS 2-3RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil
T3, T4, TSH 19-03-2025 08:14:PM T3 0.87 ng/ml 1.87-0.87 ng/mlT4 10.95 micro g/dl 12.23-6.32
micro g/dl TSH 1.05 micro Iu/ml 5.36-0.34 micro Iu/ml
BLOOD UREA 20-03-2025 04:16:AM 40 mg/dl
42-12 mg/dl HEMOGRAM 20/3/25
HAEMOGLOBIN 17.0 gm/dl TOTAL COUNT 17,300 cells/cumm
NEUTROPHILS 80 %
LYMPHOCYTES 12 %EOSINOPHILS 01 % MONOCYTES 07 %BASOPHILS 00 % PCV 51.2 vol
%M C V 79.8 fl M C H 29.1 pg M C H C 36.5 % RDW-CV 15.6 % RDW-SD 44.3 fl RBC COUNT 6.42
millions/cumm PLATELET COUNT 4.7 lakhs/cu.mmRBC Normocytic normochromic WBC leukocytosis Light Microscopy
PLATELETS Adequate Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy
IMPRESSION Normocytic normochromic blood picture with leukocytosis
SERUM CREATININE 20-03-2025 04:16:AM 0.9 mg/dl 1.3-0.9 mg/dl SERUM ELECTROLYTES (Na, K, C l) 20-03-2025 04:16:AM SODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 4.5 mmol/L 5.1-3.5
mmol/LCHLORIDE 99 mmol/L 98-107 mmol/L PROTEIN C -100.8 (19/3/25)
PROTEIN S -115.2 HEMOGRAM 21/3/25
HAEMOGLOBIN 18.0 gm/dl TOTAL COUNT 15,800NEUTROPHILS 73 % LYMPHOCYTES 17 % EOSINOPHILS 02 % MONOCYTES 08 % BASOPHILS 00 % PCV 49.9 vol %M C V 79.2 fl M C H
29.0 pg M C H C 36.7 % RDW-CV 15.1 %RDW-SD 44.0 fl RBC COUNT 6.30 PLATELET COUNT 5.5
lakhs/cu.mm RBC Normocytic normochromic WBC leukocytosis PLATELETS thrombocytosis
HEMOPARASITES No hemoparasites seen IMPRESSION Normocytic normochromic blood picture with leukocytosis and thrombocytosis
HEMOGRAM 23/3/25
HAEMOGLOBIN 19.2 gm/dl 1TOTAL COUNT 15,800 cells/cumm NEUTROPHILS 74
%LYMPHOCYTES 18 % EOSINOPHILS 02 %MONOCYTES 06 %BASOPHILS 00 %PCV 52.9 vol % M C V 80.9 flM C H 29.4 pg M C H C 36.3 %RDW-CV 16.1 %RDW-SD 45.2 flRBC COUNT 6.54
millions/cumm PLATELET COUNT 8.0 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC Increased on smear PLATELETS Increased on smear HEMOPARASITES No hemoparasites seen IMPRESSION Normocytic normochromic blood picture with leucocytosis and thrombocytosis
CT BRAIN PLAIN
IMPRESSION : NO E/O ANY HEMORRHAGES IN THE BRAIN PARENCHYMA MRI BRAIN PLAIN : DONE ON 18/3/25
IMPRESSION : ACUTE LATERAL MEDUALLRY INFARCT ON LEFT SIDE
MULTIPLE SMALL ACUTE INFRACTS IN LEFT FRONTOPARIETAL AND BILATERAL OCCIPITAL LOBES I/V/O MULTIPLICITY OF INFRACTS ,CARDIOEMBOLIC SOURCES TO BE CONSIDERED
MDCT BRAIN PLAIN DONE ON 17/3/25
IMPRESSION : SUBTLE HYPODENSITY IN LEFT PARIETO OCCIPITAL LOBES -SUGESTED MRI TO RULE OUT
CAROTID DOPPLER SONOGRAPHY DONE ON 19/3/25 IMPRESSION : NO ABNORMALITY NOTED
2D ECHO WAS DONE ON 19/03/25 IMPRESSION:
TACHYCARDIA DURING STADY NO RWMA, CONCENTRIC LVH TRIVIAL MR+, TRIVIAL AR+ MILD TR+ WITH PAH
SCLEROTIC AV ,NO AS/MS,IAS INTACT
EF-62%, RVSP 34+05 =44 MMHG GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC DYSFUNCTION
MINIMAL PE/ NO LV CLOT
IVC SIZE:1.0CMS (COLLAPSING) MILD DILATED LA/LV
Treatment Given(Enter only Generic Name) INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD INJ 10 UNITS HAI IN 25 D IV/STAT
INJ CALCIUM GLUCONATE 1 AMP IV/STAT INJ PERINORM 10 MG IV/BD
INJ MONOCEF 2 GM IV/STAT FOLLOWED BY INJ MONOCEF 1 GM IV/BD RT FEEDS MILK 100 ML WITH 2 SPOONS PROTEIN POWDER 4 TH HRLY 50 ML WATER 4 TH HRLY
TAB HOMOCHECK PO/OD
TAB ASPIRIN 300 MG PO/STAT
TAB CLOPIDOGRIL 300 MG PO/STAT TAB ATORVASTATIN 80 MG PO/STAT
TAB ECOSPRIN -GOLD 75/75/20 PO/HS 9 PM TAB ZOFER 4 MG PO/BD
TAB SPINFREE RT/BD TAB VERTIN 16 MG RT/BD
TAB CINOD 10 MG RT/OD TAB MET -XL 25 MG RT/OD
TAB PREGABA -NT 75/10 MG 9 PM HEAD END ELEVATION @45 DEGREE ORS IN 1 LIT WATER
PHYSIOTHERAPY OF LEFT UPPER LIMB ANMD LOWER LIMB
Advice at Discharge
HEAD END ELEVATION @45 DEGREE
RT FEEDS 100 ML MILK WITH 2 SPOONS PROTEIN POWDER 4 TH HRLY 50 ML WATER 4 TH HRLY
TAB REJUNEX CD3 RT/OD X 1 WEEK TAB ZOFER 4 MG RT/SOS
TAB HOMOCHECK RT/OD X 1 WEEK
TAB ECOSPRIN -GOLD 75/75/20 MG RT/HS/9 PM TO BE CONTINUED TAB VERTIN 16 MG RT/BD X 1 WEEK
TAB CINOD 10 MG RT/OD TAB MET -XL 25 MG RT/OD
TAB PREGABA -NT 75/10 MG 9 PM X 2 WEEKS PHYSIOTHERAPY OF LEFT UPPER LIMB ANMD LOWER LIMB
Follow Up
REVIEW TO GM OPD AFTER 1 WEEK WITH ANA ,APLA ,HEMOGRAM REPORTS
40 YR OLD MALE CAME TO CASUALITY WITH THE ABOVE COMPLAINTS ,ROUTINE INVESTIGATION WERE DONE ,MRI BRAIN WAS DONE I/V/O YOUND ONSET STROKE PROTEIN C , PROTEIN S , HOMOCYSTEINE LEVELAS WERE DONE WHICH WERE NORMAL
PATIENT WAS TREATED CONSERVATIVELY WITH PLACED RYLES AND FOLEYS WITH IV ANTI EMETICS ,IV PPIS, IV ANTIBIOTICS , ANTI PLATELETS ,STATINS WERE STARTED ,INJ OPTINUERON ANTI HYPERTENSIVES WERE STARTED IN VIEW OF HIGH BP RECORDINGS AND DUE TO PERSISTENT TACHYCARDIA PATIENT WAS STARTED ON BETA BLOCKERS , RT FEEDS WERE GIVEN ,FOLEYS CATHERIZATION DONE FOR INPUT OUTPUT MONITORING.
FOR SYMPTOMATICALLY TREATEMENT WE HAVE GIVEN PHYSIOTHERAPY OF LEFT UPPER AND LOWER LIMBS AND NEUROPHYSICIAN OPINION WAS TAKEN AND ADVISED FOR CONSERVATIVE MANAGEMENT WITH TAB VERTIN I/V/0 GIDDINESS AND TO RULE OUT CARDIO EMBOLIC STROKE WE HAVE DONE B/L CAROTID DOPPLER AND SHOWING NORMAL STUDY.
THUS PATIENT IS BEING DISCHARGED IN HEMODYMANICALLY STABLE WITH IMPROVEMENT IN PATIENT.
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
DISCHARGE AT REQUEST:-
PATIENT AND PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT HIS CONDITION AND ASSOCIATED RISKS AND COMPLICATIONS AND PROGNOSIS ALSO EXPLAINED AND NEED FOR NECESSARY EVALUATION AND TREATMENT IN THE OWN UNDERSTANDABLE LANGUAGE I.E TELUGU BUT THE PATIENT ATTENDERS WANT TO GET DISCHJARGE AT REQUEST
THE DOCTORS ,HOSPITAL ,STAFF NURSE AND HOSPITAL ADMINISTRATION ARE NOT RESPONSIBLE FOR ANY UNEVENTFUL OUTCOME OF THE PATIENT
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:23/3/25 Ward: MMW Unit:I
[24-03-2025 19:31] PPM 1: Patient kaise hain?
[24-03-2025 19:31] PPM 1: MRI images yahan par jaisa tha waisa hi hai
[24-03-2025 19:33] PA: Present Hyderabad
[24-03-2025 19:34] PA: Treatment
[24-03-2025 19:34] PA: Private hospital
[24-03-2025 19:34] PA: Present icu me hae
[24-03-2025 19:35] PPM 1: Alright, Kaise hain humen batate rahiyega
[24-03-2025 20:22] PA: Ha
[24-03-2025 20:22] PA: Not bad sir.
MRI report of the patient.
[25-03-2025 21.08] PPM 2: Amazingly we just saw a 66/F with Left Vertebral artery dissection causing
a Left medullary infarct with a similar presentation.
The clincher was that symptoms progressed over 90 minutes and was not static at onset.
PPM 1 - 👍
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