70M With Metabolic Syn Left Hemiparesis Telangana PaJR

 

06-03-2025

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 COLLECTIVECURRENT BEST EVIDENCE BASED INPUTS.

Afternoon ward 70M with metabolic syn developed left hemiparesis and approached local neuro who

 promptly thrombolysed with tenecteplase. He gradually developed progressive deterioration in

 sensorium

 and had to be put on the ventilator for respiratory support. He started bleeding from his ET tube

 yesterday and his PT is 29 with INR 1.9. How common is raised PT and PTTK post thrombolysis with

 tenecteplase? @PPM3

[06-03-2025 20:27] PPM 3: Raised PT and APTT post-thrombolysis with tenecteplase is uncommon but

 can occur in symptomatic ICH, fibrinogen depletion, or early DIC-like states.

[06-03-2025 20:29] PPM 3: 1) Massive Hemorrhagic Transformation of Right MCA Infarct Post-

Thrombolysis Symptomatic Intracranial Hemorrhage.

 2) Tenecteplase-Induced Coagulopathy Prolonged PT, APTT, INR.

3)  Consumptive Coagulopathy/DIC-Like State with Progressive Bleeding

[06-03-2025 21:46] PPM 1: In rabbits, tPA increased the prothrombin time and the thrombin time but

 not the partial thromboplastin time. There was no correlation between these changes in blood

 coagulation and the finding of cerebral hemorrhage. 

Unquote

https://pubmed.ncbi.nlm.nih.gov/2496332/#:~:text=tPA%20increased%20the%20prothrombin%20time,stroke%20severity%20and%20cerebral%20hemorrhage.

[06-03-2025 21:59] PPM 3: ICH post-thrombolysis is likely due to the stroke severity and infarct

 characteristics, with fibrinogen depletion playing a secondary role.

[07-03-2025 07:09] PPM 1: Our patient didn't have intracranial hemorrhage ICH post thrombolytic. He

 just had mild tracheobronchial bleed.

EMR SUMMARY

DATE OF ADMISSION:4/3/2025

 DATE OF EXPIRY:13/3/2025

 STAY IN HOSPITAL DURATION: 10 DAYS

CHIEF COMPLAINTS

  A 70 YEAR OLD MALE RESIDENT OF CAME TO CASUALTY WITH C/O WEAKNESS OF LEFT UPPER LIMB AND LOWER LIMB SINCE ONE DAY

HISTORY OF PRESENTING ILLNESS

 PATIENT WAS APPARENTLY ASYMPTOMATIC ONE DAY AGO AND THEN HE DEVELOPED WEAKNESS OF LEFT UL AND LL SINCE ONE DAY ,ASSOCIATED WITH SLURRING OF SPEECH,DEVIATION OF MOUTH TO RIGHT N/H/O INVOLUNTARY MOVEMENTS ,DEFECATION ,MICTURITION ,FROTHING FROM MOUTH,TONGUE BITE, N/H/O FEVER,COLD,COUGH,ALLERGIES , CHESTPAIN,PALPITATIONS ,SWEATING SOB,ABDOMINAL PAIN ,NAUSEA,VOMITINGS ,LOOSE STOOLS

PAST HISTORY

 N/K/C/O DM II, EPILEPSY, ASTHMA. CVA. CAD 

 H/O THROMBOLYSIS DONE ON 3/3/25 WITH INJ. TENECTEPLASE

PERSONAL HISTORY

 DIET-MIXED 

 APPETITE- NORMAL

 BOWEL MOVEMENTS- REGULAR

 BLADDER- REGULAR 

 SLEEP- ADEQUATE 

 FAMILY HISTORY: NOT SIGNIFICANT

 NO ALLERGIES

 ADDICTIONS

GENERAL EXAMINATION

 PATIENT IS CONCIOUS,COHERENT,COOPERATIVE

 TEMP: AFEBRILE

 BP:130/70MMHG MEASURED AT RIGHT ARM SUPINE

 POSITION PR:98BPM, NORMAL VOLUME AND RHYTHM

 RR:18CPM 

 SPO2:98% ON RA 

 GRBS :109MG/DL

SYSTEMIC EXAMINATION 

 CENTRAL NERVOUS SYSTEM EXAMINATION

 HANDEDNESS: 

 1. HIGHER MENTAL FUNCTIONS:

 A. CONSCIOUS 

 B. ORIENTED TO TIME, PLACE AND PERSON

 C. SPEECH: SLURRED

 D. MEMORY-INTACT

 E. DELUSIONS, HALLUCINATIONS-NO 

 F. EMOTIONAL LABILITY-NO

2. CRANIAL NERVES 

 1.OLFACTORY NERVE

 2.OPTIC NERVE III, IV, VI

 I) EXTRA-OCULAR MOVEMENTS

 II) PUPIL - NORMAL, REACTIVE TO LIGHT

 DIRECT LIGHT REFLEX :RIGHT PRESENT, LEFT PRESENT

 IV) CONSENSUAL LIGHT REFLEX: RIGHT -PRESENT, LEFT-PRESENT

 V) ACCOMMODATION REFLEX-PRESENT

 VI) PTOSIS-ABSENT 

 VII) NYSTAGMUS-ABSENT 

 VIII) HORNERS SYNDROME-NO

V

 I) SENSORY -OVER FACE AND BUCCAL MUCOSA 

 II) MOTOR MASSETER, TEMPORALIS, PTERYGOIDS

 III) REFLEX A. CORNEAL REFLEX RIGHT-PRESENT LEFT-PRESENT 

 B. CONJUNCTIVAL REFLEX RIGHT-PRESENT LEFT-PRESENT

 C. JAW JERK

VII I) MOTOR NASOLABIAL FOLD RIGHT-PRESENT LEFT-ABSENT 

 HYERACUSIS

 OCCIPITOFRONTALIS

 ORBICULARIS OCULI 

 ORBICULARIS ORIS

 BUCCINATOR 

 PLATYSMA

 II) SENSORY TASTE OF ANTERIOR 2/3RDS OF

 TONGUE(SALT/SWEET)

 SENSATION OVER TRAGUS

 II) SENSORY 

 TASTE OF ANTERIOR 2/3RDS OF

 TONGUE(SALT/SWEET)

 SENSATION OVER TRAGUS 

 III) REFLEX 

 CORNEAL-PRESENT

 CONJUNCTIVAL-PRESENT 

 IV) SECRETOMOTOR 

 MOISTNESS OF THE EYES/TONGUE AND BUCCAL MUCOSA PRESENT

VIII

1) RINNES TEST

 II) WEBERS TEST

 III) NYSTAGMUS

 IX, X

 I) UVULA, PALATAL ARCHES, AND MOVEMENTS

 CENTRALLY 

 II) GAG REFLEX: PRESENT

 III) PALATAL REFLEX: PRESENT

MOTOR SYSTEM

BULK                                                      R                                                    L

Inspection                                           NORMAL                                   NORMAL

Palpation                                            NORMAL                                   NORMAL

Measurements

UL                                                           30cm                                        30cm

LL                                                           50cm                                        50cm

TONE                                                     R                                                  L

UL                                                    NORMAL                                HYPERTONIA

LL                                                    NORMAL                                HYPERTONIA

MOTOR SYSTEM

POWER                                                   R                                                  L

Neck muscles                                        Good                                            Good

UL                                                          5/5                                                  1/5

LL                                                          5/5                                                  1/5

Trunk muscles                                       Good                                             Good

REFLEXES

Superficial Reflexes                               R                                                   L

Corneal                                             Present                                            Present

Conjunctival                                     Present                                            Present

Gag                                                   Present                                            Present

Deep Tendon Reflexes                           R                                                    L

Jaw jerk                                                  -                                                      -

Biceps jerk                                           +2                                                     -

Triceps jerk                                           -                                                       -

Supinator                                              -                                                       -

Knee jerk                                              +2                                                    +

Ankle jerk                                              -                                                      -

Plantar                                            Extensor                                                 -

OTHER SYSTEM EXAMINATION

 CARDIOVASCULAR SYSTEM: JVP NOT RAISED, HEART

 SOUNDS-S1, S2 HEARD, NO THRILLS/MURMURS

 RESPIRATORY SYSTEM: BILATERAL AIR ENTRY

 PRESENT, NORMAL VESICULAR BREATH SOUNDS

 HEARD, NO ABNORMAL/ADDED SOUNDS

 PER ABDOMEN: SOFT, NON-TENDER

PROVISIONAL DAIGNOSIS 

 1.LARGE RECURRENT ISCHEMIC CVA (1ST EPISODE ON 04/03/25 2ND EPISODE ON

 06/03/25) WITH SUBACUTE INFRACT ON RIGHT FRONTO PARIETAL LOBES EXTENDING TO

 RIGHT STRIATOCAPSULAR REGION CAUSING MASS EFFECT ON IPSILATERAL

 VENTRICLE WITH POOR GCS WITH RESPIRATORY DEPRESSION ON MECHANICAL

 VENTILATION FOR 5 DAYS AND EXTUBATED

 2.INTRACRANIAL HYPERTENSION WITH TACHYARRYTHIMAS (SVT, SINUS TACHYARRYTHMIA) 

 S/P THROMBOLYSIS WITH TNK 3/3/25(IN OUTSIDE HOSPITAL) 

 3.PRE RENAL AKI WITH ALI /ATN CENTRAL FEVER

 4.SEPSIS SEC TO CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION S/P EXTUBATION DAY -3

 5.? HAP 

6. K/C/O HTN SINCE 7 YEARS

INVESTIGATIONS

 Heamogram 4/3/25      6/3/25     8/3/25      9/3/25      10/3/25       11/3/25         13/3/25

 Hb               12.5           11.4        10.7          11.4          11.4            12.1               14.7

 TLC             9,300        11,000       6,800     8,500        7,500           9,400           22,600

 PCV              33.8          30.6          30.8       32.5         33.6              35.5              44 

 MCV             81.4          80.3          83.4        83.6         84.4             84.6              85.5 

 RBC              4.15          3.81          3.69        3.89        3.98              4.19              5.15 

 PLT               1.8            1.54         1.51        1.50         1.5               1.68               2.54 

 SMEAR Normocytic, normochromic   4/3/25

 Normocytic, normochromic                  6/3/25

 Normocytic, normochromic                  8/3/25

 Normocytic, normochromic                  9/3/25

 Normocytic, normochromic                 10/3/25

 Normocytic, normochromic                 11/3/25

 Normocytic, normochromic                 13/3/25

INVESTIGATIONS

 RFT                  4/3/25         6/3/25          8/3/25          9/3/25         10/3/25              12/3/25           13/3/25

 UREA                  17              21                 37               44                  58                     72                     91 

 CREATININE    1.0              0.9             1.0                0.9                  1.3                    1.3                   1.5

 Na+                     141             137            140               143                145                   146                   148

 K+                        4.2             3.7              3.5                3.4                3.3                     3.7                  5.4

 Cl-                       103              99             103              105                106                   105                  106

INVESTIGATIONS

 LFT                     4/3/25                        8/3/25                 10/3/25                 11/3/25                  13/3/25

 TB                         1.00                         1.74                        1.69                        2.10                      1.71

 DB                         0.28                         0.35                       0.36                        0.33                      0.39

 SGOT                     19                            41                         55                            52                         111

 SGPT                     10                           21                          47                            53                          126

 ALP                      130                          92                           93                            91                           80

 TP                           6                          5.4                          5.8                             6.2                        5.8 

 ALB                     1.39                        2.8                         2.85                            3.22                     2.76

INVESTIGATIONS

 ABG                        PH                           PCO2                                PO2                                   HCO3

5/3/25                      7.43                            26.3                                   48                                     17.5

6/3/25 (7am)           7.45                             26.5                                  126                                     18.5

6/3/25 (8pm)           7.41                             30.6                                  93.2                                    19.3

7/3/25                       7.37                            37.2                                  55.8                                    21.3

8/3/25 (7am)           7.45                             25.5                                 152                                      17.6

8/3/25 (1pm)            7.36                            37.8                                  49.9                                    21.3

10/3/25 (7am)          7.43                            36.1                                  86.2                                    23.9

10/3/25 (7pm)          7.46                            29.6                                  51.9                                    20.8

11/3/25                     7.41                           39.4                                   74.6                                    24.7

12/3/25                    7.44                            35.3                                    67.4                                    24

INVESTIGATIONS

                                           6/3/25                          11/3/25

 APTT                                 50 sec                            33 sec 

 PT                                       25 sec                           16 sec 

 INR                                     1.85                                1.11

INVESTIGATIONS

Lipid Profile                               5/3/25

 Total Cholestrol                            140 

 Triglycerides                                 70 

 HDL Cholesterol                          34.4

 LDL Cholesterol                            92

 VLDL                                           14

ECG ON 5/3/25

9/3/25

13/3/25

MRI BRAIN

 IMPRESSION: ACUTE INFARCT IN RIGHT TEMPORAL 

 AND RIGHT FRONTOPARIETAL LOBES 

 AND RIGHT STRIOTOCAPSULAR REGION -MCA

 TERRITORY INFARCT

CT BRAIN

HRCT CHEST

2D ECHO

 

 PRESENT APC'S + DURING STUDY 

 NO RWMA MILD LVH +

 TRIVIAL TR+, NO PAH; TRIVIAL AR +, NO MR

 SCLEROTIC AV: NO AS/MS IAS -INTACT

 EF - 63 %, GOOD LV SYSTOLIC FUNCTION

 GRADE I DIASTOLIC DYSFUNCTION

 NO PE: NO LV CLOT 

 IVC SIZE (1.50 CM) COLLAPSING

URINE CULTURE

ET CULTURE

TREATMENT GIVEN 

 1. HEAD END ELEVATION

2. RT FEEDS 100 ML MILK WITH 2TBSP PROTEIN POWDER 4 HOURLY,50 ML WATER 2 HOURLY

3. IV FLUIDS NS@50ML/HR

4. INJ.CLINDAMYCIN 600MG IV/TID

5. INJ.PANTOP 40 MG IV/OD AT 7 AM

6. INJ.LEVITERICETAM 500MG IV/BD

7. INJ.B COMPLEX WITH VITAMIN B12(OPTINEURON) IN 100 ML NS IV/OD

TREATMENT GIVEN 

 8.INJ. LASIX 10MG IV/BD 

 9.INJ.MANNITOL 20% IV/BD

 10.INJ. PCM 1GM IV/SOS 

 11.INJ. AMIODARONE 900MG IN 500ML NS INFUSION @33.3ML/HR FOR 6HRS FOLLOWED BY INJ. AMIODARONE 540MG FOR NEXT 18HRS @16.6ML/HR 

 12.TAB. ATORVASTATIN 20MG RT/OD 9PM 

 13.TAB. PIRACETAM 800MG + CITICOLINE 500MG RT/BD 

 14.TAB. BROMOCRIPTINE 5MG RT/QID 

 15.TAB. STROCIT-P

DEATH SUMMARY 

 A 70 YEAR OLD MALE PATIENT K/C/O HYPERTENSION SINCE 7 YEARS PRESENTED TO CASUALITY WITH C/O WEAKNESS OF LEFT UPPER AND LOWER LIMBS SINCE 1 DAY WITH SLURRING OF SPEECH AND DEVIATION OF MOUTH . ON PRESENTATION HIS VIATLS WERE PR:98BPM, BP:130/70MMHG, RR:18CPM SPO2:98%'RA GRBS:109MG/DL GCS:E4V2M6 RYLE'S TUBE WAS PLACED AND SUPPORTIVE TREATMENT WAS INITIATED RELEVANT INVESTIGATIONS WERE DONE AND MRI BRAIN (PLAIN) WAS DONE THAT SHOWED ACUTE INFRACT IN RIGHT FRONTO-PARIETAL AND TEMPORAL AND RIGHT STRIATOCAPSULAR REGION INVOLVING RIGHT MCA TERITORY PATIENT INITIALLY WENT TO OUTSIDE HOSPITAL AND CT-BRAIN DONE THAT SHOWED INFRACT FOR WHICH THROMBOLYSIS WAS DONE WITH INJ.TENECTEPLASE AND WAS REFERRED HERE FOR FURTHER MANAGEMENT ON DAY2 : PATIENT'S GCS WORSENED. GCS WAS E2V2M4 AND PATIENT DEVELOPED TYPE 1 RESPIRATORY FAILURE WITH ABG SHOWING PH:7.43, PCO2: 26MMHG, PO2: 48MMHG, SO2: 70%, HCO3-: 17.5MM/DL. PATIENT WAS THEN ELECTIVELY INTUBATED AND CONNECTED TO MECHANICAL VENTILATOR.BLOOD INVESTIGATIONS WERE WITHIN THE NORMAL RANGE.DUE TO SUDDEN FALL IN GCS RECURRENT CVA WAS SUSPECTED AND A REVIEW CT BRAIN WAS DONE THAT SHOWED LARGE SUBACUTE INFRACT IN RIGHT FRONTO-PARIETAL LOBES EXTENDING TO RIGHT STRIATOCAPSULAR REGION CAUSING MASS EFFECT IN IPSILATERAL VENTRICLE WITH MIDLINE SHIFT OF 11-12MM TOWARDS LEFT SIDE WITH DILATION OF CONTRALATERAL VENTRICLE. OSMOTIC DIURETIC ( INJ. MANNITOL 20% ) WAS INITIATED. SUPPORTIVE ANTIBIOTIC THERAPY AND SYMPTOMATIC TREATMENT WAS CONTINUED. PATIENT HAD CONTINUOUS FEVER SPIKES. PATIENT WAS MAINTIANING ON ACMV-VC MODE AND GRADUALLY WEANED OFF TO SIMV-VC MODE AND THEN TO CPAP-VC MODE 

DEATH SUMMARY 

 DAY2: PATIENT'S GCS WORSENED. GCS WAS E2V2M4 AND PATIENT DEVELOPED TYPE 1 RESPIRATORY FAILURE WITH ABG SHOWING PH:7.43, PCO2: 26MMHG, PO2: 48MMHG, SO2: 70%, HCO3-: 17.5MM/DL. PATIENT WAS THEN ELECTIVELY INTUBATED AND CONNECTED TO MECHANICAL VENTILATOR.BLOOD INVESTIGATIONS WERE WITHIN THE NORMAL RANGE.DUE TO SUDDEN FALL IN GCS RECURRENT CVA WAS SUSPECTED AND A REVIEW CT BRAIN WAS DONE THAT SHOWED LARGE SUBACUTE INFRACT IN RIGHT FRONTO-PARIETAL LOBES EXTENDING TO RIGHT STRIATOCAPSULAR REGION CAUSING MASS EFFECT IN IPSILATERAL VENTRICLE WITH MIDLINE SHIFT OF 11-12MM TOWARDS LEFT SIDE WITH DILATION OF CONTRALATERAL VENTRICLE. OSMOTIC DIURETIC ( INJ. MANNITOL 20% ) WAS INITIATED. SUPPORTIVE ANTIBIOTIC THERAPY AND SYMPTOMATIC TREATMENT WAS CONTINUED. PATIENT HAD CONTINUOUS FEVER SPIKES. PATIENT WAS MAINTIANING ON ACMV-VC MODE AND GRADUALLY WEANED OFF TO SIMV-VC MODE AND THEN TO CPAP-VC MODE

DEATH SUMMARY 

 ON DAY 5 OF INTUBATION (10/3/25) PATIENT WAS MAINTAINING WITH T-PIECE WITH 10L OF O2 SUPPORT AND WAS WEANED OFF VENTILATORY SUPPORT AND EXTUBATED. PATIENT WAS MAINTAINING WITH 4L O2 SUPPORT BUT PATIENT SHOWED NO IMPROVEMENT IN GCS BUT VITALS WERE MAINTAINED PATIENT WAS HAVING CONTINUOUS FEVER SPIKES AFTER EXTUBATION I/V/O? CENTRAL FEVER FOR WHICH TAB.BROMOCRIPTINE WAS STARTED. ON 12/3/25 PATIENT DEVELOPED TACHYARRYTHMIA SVT AND SINUS TACHYARRYTHMIA (?SECONDARY TO CONTINUOUS FEVER SPIKES) AND INJ.AMIODARONE 150 MG IV STAT WAS GIVEN BUT NOT REVERTED. FURTHER INJ.ADENOSINE WAS ALSO GIVEN AND FIBRILLATION REVERTED TO NORMAL SINUS RHYTHM REPEAT CT-BRAIN WAS DONE THAT SHOWED NO REDUCTION IN COMPRESSION SECONDARY TO INFARCT. PATIENT HAD TACHYPNOEA (RR >30CPM) SINCE 7 AM ON 13/3/25 AT AROUND 12:30 PM PATIENT GRADUALLY DEVELOPED DESATURATION AND BRADYCARDIA I/V/O ABSENT CENTRAL AND PERIPHERAL PULSES. CPR WAS INITIATED ACCORDING TO LATEST ACLS GUIDELINES AND CONTINUED FOR 30 MINUTES.INSPITE OF ALL THESE RESUSCITATION EFFORTS PATIENT COULDN'T BE REVIVED AND DECLARED DEAD AT 1:05PM ON 13/3/25

>IMMEDIATE CAUSE: 

 RESPIRATORY FAILURE SECONDARY TO? INCREASED ICT? HAP

 >ANTECEDENT CAUSE OF DEATH:

 RECURRENT CVA WITH AIS WITH LARGE SUBACUTE INFRACT ON RIGHT FRONTO PARIETAL LOBES EXTENDING TO RIGHT STRIATOCAPSULAR REGION CAUSING MASS EFFECT ON IPSILATERAL VENTRICLE WITH RIGHT HEMPARESIS WITH K/C/O HYPERTENSION WITH SINUS TACHYARYTHMIAS-REVERTED TO NSR WITH? HAP WITH AKI, ALI WITH S/P THROMBOLYSIS (INJ.TENEKTEPLASE) WITH S/P EXTUBATION DAY-3