13-06-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER 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.
[13-06-2025 20.02] PPM 1: Yesterday's clinical meeting discussion inspired us to share one of our similar patients to be archived by CR.
[13-06-2025 20.07] PPM 1: While discussing in the meeting we realised we have a similar patient who's clinical complexity of stroke, coma and fever had compelled us to start her on all available interventions such as antibacterials as well as antimalarials for suspected cerebral malaria as delineated in this time line since admission.
[13-06-2025 20.22] PPM 1: Clinical phenotype and handwritten notes and an ECG that makes @PPM4's thesis.
EMR SUMMARY
80 Years/Female
Discharge Type: Relieved
Admission Date: 05/06/2025 11:46 AM
Diagnosis ACUTE CVA-ICHEAMIC STROKE WITH LEFT HEMIPLEGIA WITH UMN TYPE FACIAL PALSY INVOLVING RIGHT MCA TERRITORY -RIGHT FRONTO PARIETO TEMPORAL INFARCT SECONDARY TO CARDIOEMBOLIC STROKE
RECURRENT CVA
ASPIRATION PNEUMONIA
ATRIAL FIBRILLATION WITH FVR (CONTROLLED)
CLINICAL MALARIA
PRERENAL AKI(RESOLVED)
K/C/O DM TYPE 2 (HBA1C- 7.6%) SINCE 4 YEARS
K/C/O HTN SINCE 4 YEARS
GRADE 2 BED SORE OVER LEFT GLUTEAL REGION
Case History and Clinical Findings C/O ALTERED SENSORIUM, SLURRED SPEECH, WEAKNESS OF LEFT UPPER LIMB AND LOWER LIMB SINCE 2 DAYS
HOPI- PATIENT WAS APPARENTLY ALRIGHT 2 DAYS BACK THEN SHE DEVELOPED ALTERED SENSORIUN APHASIAFOR WHICH SHE WAS TAKEN TO NEARBY HOSPITAL AND FOUND TO BE HYPOGLYCEMIC AND GOTN TREATED LATER FOUND TO BE HAVING REDUCED MOVEMENT OF LEFT HAND AND FOOT AND DEVIATION OF MOUTH WITH SLURRED SPEECH.
NO H/O CHEST PAIN, CHEST TIGHTNESS H/O SOB GRADE SINCE 3 MONTHS, INVOLUNTARY MICTURATION, DEFECATION AND PEDAL EDEMA
NO HO ABDOMINAL PAIN
PAST HISTORY)
K/C/O DM -VILDAGLIPTIN+-METFORMIN (50/500) PO/OD
H/C/O HTN-TELMA AM SINCE 4 YEARS PO/OD PERSONAL HISTORY: MIXED DIET, APPETITE NORMAL, REGULAR BOWEL MOVEMENTS, MICTURITION NORMAL, NO KNOWN ALERGIES NO KNOWN ADDICTIONS
FAMILY HISTORY: NOT SIGNIFICANT GENREAL EXAMINATION: PEDAL EDEMA PRESENT,PALLOR PRESENT NO ICTERUS, CYANOSIS, LYMPHADENOPATHY, MALNUTRITION VITALS:- TEMP: AFEBRILE, BP: 120/70 MMHG, RR: 16CPM, PR: 96 BPM, SPO2: 96% AT RA, GRBS 148 MG% SYSTEMIC EXAMINATION:- CVS-NORMAL, RS-NORMAL,PA: NORMAL
CNS:
OH
GCS-E2V1M5
MOTOR:
RT LT
POWER
U/L 4/5 0/5
L/L 4/5 0/5
TONE U/L NORMAL NORMAL L/L NORMAL NORMAL
REFLEXES RT LT
BICEPS +2_
TRICEPS+_
SUPINATOR _ _
KNEE+_
ANKLE_ _
PLANTAR FLEXION EXTENSION
CRANIAL NERVES: FASCIAL NERVE(TH NERVE): NO DEVIATION OF MOUTH? NO DROOLING OF SALIVA
NIHSS STROKE SCALE: ON 5/6/2025:MODERATE STROKE(14) ON 6/6/2025:MODERATE STROKE(Z) SURGRY REFERRAL WAS DONE ON 10/6/25 I/IO BED SORES ADVISED FOR ASD, POSITION CHANGE 2 HRLY, ALPHA BED
CARDIOLOGY REFERRAL WAS DONE ON 9/6/25 I//O ATRIAL FIBRILLATION COURSE IN HOSPITAL:80 YR OLD FEMALE CAME WITH THE ABOVE COMPLAINTS. PATIENT WAS EVALUATED CLINICALLY WITH APPROPRIATE INVESTIGATIONS WAS DIAGNOSED AS 1.ACUTE CVA-ICHEAMIC STROKE WITH LEFT HEMIPLEGIA WITH UMN TYPE FACIAL PALSY INVOLVING RIGHT MCA TERRITORY -RIGHT FRONTO PARIETO TEMPORAL INFARCT SECONDARY TO CARDIOEMBOLIC STROKE 2.RECURRENT CVA 3.ASPIRATION PNEUMONIA 4.ATRIAL FIBRILLATION WITH FVR 5.CLINICAL MALARIA 6.PRERENAL AKI 7.K/C/O DM TYPE 2 (HBA1C-7.6%) SINCE 4 YEARS 8.K/C/O HTN SINCE 4 YEARS. PATIENT WAS STARTED ON INTRAVENOUS FLUIDS, RT FEEDS (MILK+PROTEIN POWDER).GRBS 7 POINT MONITORING WAS DONE AND WAS STARTED ON INSULIN AND OHA. TEMPERATURE CHARTING WAS DONE 4 HRLY I/VIO FEVER SPIKES PATIENT WAS STARTED ON ANTIBIOTICS INJ MONOCEF 2 GM IVBD, INJ.AGUMENTIN 1.2GM IV/BD,INJ VANCOMYCIN 1.2 GM IVITID, ANTIMALARIALS, ANTIVIRALS, ANTIFUNGALS, ANTIPYRETICS.PATENT GCS IMPROVED AND IS HEMODYNAMICALLY STABLE HENCE BEING DISCHARGED WITH RYLE'S TUBE, FOLEY'S URINARY CATHETER AND CENTRAL LINE IN SITU,
Investigation COMPLETE URINE EXAMINATION (CUE) 05-06-2025 COLOUR Pale yellow, APPEARANCE Clear. REACTION Acidic, SP.GRAVITY 1.010, ALBUMIN +,SUGAR +,BILE SALTS Nil, BILE PIGMENTS Nil, PUS CELLS 2-3, EPITHELIAL CELLS 3-4, RED BLOOD CELLS Nil, CRYSTALS Nil, CASTS Nil, AMORPHOUS DEPOSITS Absent, OTHERS Nil HBsAg-RAPID 05-06-202 Negative Anti HCV Antibodies - RAPID 05-06-2025 Non Reactive RFT 05-06-2025, UREA 21 mg/dI ,CREATININE 0.8 mg/dI, URIC ACID 2.3 mmo/L ;CALCIUM 9.4 mg/dI, PHOSPHOROUS 3.0 mg/dI, SODIUM 137 mmoVL, POTTASIUM 2.8 mmo/L, CHLORIDE 101 mmol/L
ABG 05-06-2025 PH 7.41, PCO2 22.6, P02 98.2, HCO3 14.3, St.HCO3 17.6, BEB -8.5, BEecf 9.4, TC02 29.4,02 Sat 97.8,02 Count 14.3
LIVER FUNCTION TEST (LFT) 05-06-2025: Total Bilurubin 2.04 mg/dl, Direct Bilurubin 0.45 mg/dl SGOT(AST) 22 IU/L ,SGPT(ALT) 10 IU/L, ALKALINE PHOSPHATASE 246 IU/L, TOTAL PROTEINS 7.1 gm/dl, ALBUMIN 4.1 gm/dl, A/G RATIO 1.37SERUM ELECTROLYTES (Na, K, C I) 05-06- 2025,SODIUM 138 mmol/L ,POTASSIUM 3.8 mmoI/L, CHLORIDE 105 mmol/L HEMOGRAM ON 5-06-2025: HAEMOGLOBIN 11.6 gm/dl, TOTAL COUNT 10,200 cells/cumm, NEUTROPHILS 76 % , LYMPHOCYTES 15 % , EOSINDOPHILS 04 %, MONOCYTES 5 % BASOPHILS 00 % , PCV 35.2 vol % M C V 91.5 f, M C H 30.2 pg. M C H C 33.1 %, RDW-CV 15.8 % , RDW-S 53 fl, RBC COUNT 3.84 milions/cumm, PLATELET COUNT 2.49 lakhs/cu.mm SMEAR: RBC Normocytic normochromic, WBC normal, PLATELETS Adeqaute, No hemoparasites seen, IMPRESSION Normocytic normochromic blood picture
MRI BRAIN ON 5/6/25: ACUTE INFARCT IN RIGHT FRONYOTEMPORAL AND
LOBES-MCA INFARCTTROPONIN- ON 6/6/25:-11.1pg/mlHbA1c DONE ON 7/6/25:- 7.6% RIGHT PARIETAL COMPLETE URINE EXAMINATION (CUE) 07-06-2025 COLOUR REDDISH,APPEARANCE Clear, REACTION Acidic, SP.GRAVITY 1.010,ALBUMIN++++,SUGAR +, BILE SALTS Nil, BILE PIGMENTS Nil, PUS CELLS 10-11,EPITHELIAL CELLS 4-5,RED BLOOD CELLS PLENTY, CRYSTALS Nil, CASTS Nil, AMORPHOUS DEPOSITS Absent, OTHERS Nil RFT 07-06-2025.UREA 52 mg/dl CREATININE 0.9 mg/dl, URIC ACID 3.5 mmo/L CALCIUM 9 8 mg/dI, PHOSPHOROUS 4.6 mg/dI, SODIUM 142 mmol/L, POTASSIUM 3.8 mmol/L, CHLORIDE 105 mmol/L
COMPLETE URINE EXAMINATION (CUE) 07-06-2025 COLOUR PALE YELLOW,APPEARANCE Clear, REACTION Acidic, SP.GRAVITY 1.010, ALBUMIN +++,SUGAR+ BILE SALTS Nil, BILE PIGMENTS Nil, PUS CELLS 4-5, EPITHELIAL CELLS 2-4, RED BLOOD CELLS NIL, CRYSTALS Nil, CASTS Nil, AMORPHOUS DEPOSITS Absent, OTHERS NiI
ON 7/6/25: - SPOT URINEPROTEIN27mg/dI. SPOTURINECREATININE 187.8mg/dI. RATIO0.14 HEMOGRAM ON 7-06-2025: HAEMOGLOBIN 11.6 gm/dI, TOTAL COUNT 15,000 cells/cumm, NEUTROPHILS 77 %, LYMPHOCYTES 13 %, EOSINOPHILS 01 %, MONOCYTES 09 %, BASOPHILS 00 %, PCV 37.9 vol %, M C V 86.1 f1, M C H 30.9 pg, M C H C 35.9 %. RDW-CV 14.8 %, RDW-SD 48.2 fl, RBC COUNT 4.4 millions/cumm, PLATELET COUNT 2.45 lakhs/cu.mm
SMEAR: RBC Normocytic normochromic, WBC normal, PLATELETS Adeqaute No hemoparasites seen, IMPRESSION Normocytic normochromic blood picture COMPLETE URINE EXAMINATION (CUE) 08-06-2025 COLOUR Pale yellow, APPEARANCE Clear, REACTION Acidic, SP.GRAVITY 1.010,ALBUMIN ++,SUGAR +,BILE SALTS Nil, BILE PIGMENTS Nil, PUS CELLS 56, EPITHELIAL CELLS 2-4, RED BLOOD CELLS NiI, CRYSTALS Nil, CASTS NiI, AMORPHOUS DEPOSITS Absent, OTHERS Nil
SERUM ELECTROLYTES ON 10/6/25: - SODIUM 142 mmoV/L, POTASSIUM 3.5 mmoI/L, CHLORIDE 104 mmol/L, CALCIUM IONIZED 1.06 mmol/L TROPONIN-I ON 8/6/25:-23.4pg/ml
HEMOGRAM ON 8-06-2025: HAEMOGLOBIN 12.1 gm/dl TOTAL COUNT 12,900 cells/cumm, VEUTROPHILS 73 ofo LYMPHOCYTES 17 % EOSINOPHILS 01 %, MONOCYTES 09 %, BASOPHILS 00 9% PCV 34.7 vol % M CV86.8 fl,M CH 30.3pg, MCHC34.9 %, RDW-CV 15 % RDW-SD 48.3 fl, RBC COUNT 4 millions/cumm, PLATELET COUNT 2.12 lakhs/cu.mm SMEAR: RBC Normocytic normochromic, WBC normal, PLATELETS Adeqaute , No hemoparasites seen, IMPRESSION Normocytic normochromic blood picture HEMOGRAM ON 9-06-2025: HAEMOGLOBIN 12.4 gm/dI, TOTAL COUNT 12,300 cells/cumm, NEUTROPHILS 76 % , LYMPHOCYTES 15 % , EOSINOPHILS 01_%, MONOCYTES 08 % BASOPHILS 00 % , PCV 37.5 vol % , M C V 93.8 fl , M C H 31 pg, M C H C 33 %, RDW-CV 15 %, RDW-SD 51 fi, RBC COUNT 4 millions/cumm, PLATELET COUNT 1.93 lakhs/cu.mm SMEAR: RBC Normocytic normochromic, WBC normal, PLATELETS Adeqaute , No hemoparasites seen, IMPRESSION Normocytic normochromic blood picture RFT 09-06-2025,UREA 109 mg/dI ,CREATININE 1.0 mg/dI, URIC ACID 4.2 mmol/L, CALCIUM 10.0 mg/dl PHOSPHOROUS 4.68 mg/dI, SODIUM 142mmol/L, POTASSIUM 3.68 mmoI/L, CHLORIDE 104 mmo/L
2D ECHO WAS DONE ON 9/6/25: IMPRESSION- EF: 52%, SINUS ARRHYTHMIA, CALCIFIED AV, GRADE I DIASTOLIC DYSFUNCTION, FAIR LV SYSTOLIC FUNCTION BLOOD, URINE, CSF CULTURE AND SENSITIVITY ON 9/6/25: NO BACTERIAL GROWTH MRI BRAIN WAS DONE ON 9/6/25:- LARGE ACUTE INFARCT IN RIGHT FRONTAL AND PARIETAL LOBES INVOLVING BOTH GRAY AND WHITE MATTER AND RIGHT LENTIFORM NUCLEUS-MCA TERRITORY INFARCT RFT 09-06-2025 UREA 89 mg/dl CREATININE 0.9 mg/d,URIC ACID 4.0 mmoV/L CALCIUM 10.0 mg/dl, PHOSPHOROUS 3.77 mg/dI, SODIUM 143 mmoV/L POTASSIUM 3.3 mmol/L, CHLORIDE 102 mmol/L
HEMOGRAM ON 10-06-2025: HAEMOGLOBIN 12,4 gm/dl, TOTAL COUNT 12,600 cells/cumm, NEUTROPHILS 78 % , LYMPHOCYTES 15 % ,EOSINOPHILS 01 %, MONOCYTES 06 %, BASOPHILS 00 % , PCV 38.2 vol % , M C V 94.6 fl , M C H 30.6 pg, M C H C 32.4 %, RDW-CV 15.2 % , RDW-SD 51.8 fl, RBC COUNT 4 millions/cumm, PLATELET COUNT 1.9 lakhs/cu.mm SMEAR: RBC Normocytic normochromic, WBC normal, PLATELETS Adeqaute , No hemoparasites seen, IMPRESSION Normocytic normochromic blood picture SERUM ELECTROLYTES ON 10/6/25:-SODIUM 142 mmoVL, POTASSIUM 3.5 mmol/L, CHLORIDE 104 mmol/L, CALCIUM IONIZED 1.06 mmol/L ABG 10/6/25:-PH 7.37 PCO2 33.7 mmHg 02 90.0 mmHg HCO3 19.3 mmol/LSt.HCO3 20.5 mmol/LBEB-4.7 mmol/LBEecf-5.0 mmol/LTCO2 39,5 VOLO2 Sat 96.7 %02 Count 15.6 vol % MALARIALPARASITE ON 10/6/25:-Negative (-ve) PERIPHERALSMEAR ON 10/6/25:-RBC : Normocytic normochromic WBC : increased count on smear PLATELET: Adequate imp ; Normocytic normochromic with leukocytosis.
CHEST X RAY ON 10/6/25:- FEW ILL DEFINED HOMOGENOUS LINEAR OPACITIES IN UPPER AND LOWER LOBES OF RIGHT LUNG AND IN UPPER LOBE OF LEFT LUNG TRUENAT MTB 10/6/25:- NOT DETECTED
ABG 11/6/25:- PH 7.43 PCO2 31.5 mmHg P02 50.3 mmHg HCO3 20.7 mmol/LSt.HCO3 22.2 mmol/LBEB-2.4 mmol/L BEecf-2.9 mmol/LTCO2 41.9 VOLO2 Sat 85.4 %02 Count 13.9 vol %
HEMOGRAM 11/6/25:-HAEMOGLOBIN 12.1 gm/dI TOTAL COUNT 13,000 cells/cumm NEUTROPHILS 12 % LYMPHOCYTES 21 % EOSINOPHILS 01 % MONOCYTES 06 %BASOPHILS 00 %PCV 36.8 vol %M C V 94.0 fl M C H 30.9 pg M C H C 32.9 %RDW-CV 15.0 %RDW-SD 50.8 fl RBC COUNT 3.92 millions/cumm PLATELET COUNT 1.98 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC With in normal limits PLATELETS Adeqaute HEMOPARASITES No hemoparasites seen IMPRESSION Normocytic normochromic blood picture with leukocytosis URINE, BLOOD CULTURE AND SENSITIVITY: NO GROWTH RFT 11/6/25:-UREA 62 mg/dI CREATININE 0.8 mg/dI URIC ACID 3.0 mmol/L CALCIUM 10.1 mg/dl PHOSPHOROUS 2.69 mg/dl SODIUM 139 mmol/L POTASSIUM 4.5 mmoV/L 11/6/25:
APTT TEST 38 Sec,D-DIMER 3230 ng/ml, Prothrombin Time 20 Sec, INR 1.4 12/6/25:-
HEMOGRAM: HAEMOGLOBIN 11.9 gm/dI TOTAL COUNT 13,700 cells/cummNEUTROPHILS 78 % LYMPHOCYTES 15 %EOSINOPHILS 01 %MONOCYTES 06 %BASOPHILS 00 %PCV 36.7 vol %M C V 92.7 fl M C H 30.1 pg M C H C 32.5 %RDW-CV 14.9 %RDW-SD 50.1 fi RBC COUNT 3.96 millions/cumm PLATELET COUNT 1.89 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC increased count on smear PLATELETS Adeqaute HEMOPARASITES No hemoparasites seenlMPRESSION Normocytic normochromnic wíth leukocylosis
SERUM ELECTROLYTES (Na, K, C I) SODIUM 136 mmo/L POTASSIUM 3.5 mmol/L CHLORIDE 104 mmol/LCALCIUM IONIZED 1.09 mmol/L
13/6/25:-HEMOGRAM:HAEMOGLOBIN 11.5 gm/dI TOTAL COUNT 10,000 cells/cumm NEUTROPHILS 75 % LYMPHOCYTES 13 % EOSINOPHILS 02 % MONOCYTES 10 % BASOPHILS 00 % PCV 32.6 vol % M C V 86.2 fi M C H 30.4 pg M C H C 35.3 %RDW-CV 14.0 %RDW-SD 45.1 fl RBC COUNT 3.78 millions/cumm PLATELET COUNT 2.12 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC With in normal limits PLATELETS Adequate in number and distribution HEMOPARASITES No hemoparasites seen IMPRESSION Normocytic normochromic blood picture
RFT: UREA52 mg/dI CREATININE 0.8 mg/dI URIC ACID 2.0 mmol/L CALCIUM 9,2 mg/dl PHOSPHOROUS 2.7 mg/dl SODIUM 135 mmol/L POTASSIUM 3.5 mmol/L.CHLORIDE 101 mmol/L 98-107
Treatment Given (Enter only Generic Name)
RT FEEDS 75ML MILK WITH 2 SCOOPS OF PROTEIN POWDER 4 HRLY RT FEEDS 100 ML WATER HRLY IVF 0.9%NS
AT 75 ML/HR INJ MONOCEF 2 GM IV/BD INJ.AGUMENTIN 1.2GM IV/BD INJ VANCOMYCIN 1.2 GM IVITID INJ FALCIGO 120MG IV 0-12-24 INJ.PAN 40MG IV/OD INJ CLINDAMYCIN 600 MG IV/BD
INJ ENOXAPARIN-6O S/C OD INJ.HAI S/C TID ACCORDING TO GRBS INJ.NEOMOL 1GM IVISOS(IF TEMPERATURE >101F) INJ VIT K 10 MG/ML IMOD(DEEP IM) TAB.DOLO 650MG RT/TID
TAB.ECOSPIRIN-GOLD (75-75-20)RT/HS TAB.STROCIT PLUS RT/OD
TAB.TELMA 20MG RT/OD TAB BISOPROLOL 2.5 MG RT/BD TAB FLUCONAZOLE 150MG RT/OD TAB GABAPENTIN 150MG RT/HS TAB OSELTAMAVIR 75 MG RT/BD TAB.METFORMIN 500MG RT/OD TAB LARIGO DS KIT RT/OD
NEOSPORIN POWDER FOR L/A GRBS 7 POINT MONITORING TEMPERATURE CHARTING 4 TH HOURLY POSITION CHANGE 2ND HOURLY REGULAR PHYSIOTHERAPY OF LEFT UPPER AND LOWER LIMBS Advice at Discharge RT FEEDS 75ML MILK WITH 2 SCOOPS OF PROTEIN POWDER 4 HRLY RT FEEDS 100 ML WATER HRLY INJ HAI SC/TID 6UNITS-6UNITS-6UNITS TAB TAXIM O 200 MG RT/BD X 5 DAYS TAB FLUCONAZOLE 150MG RT/OD X 5 DAYS
TAB CLINDAMYCIN 300 MG RT/BD X 5 DAYS TAB LARIGO DS KIT RT/OD X 2DAYS TAB.PAN 40MG RT/OD X 5 DAYS TAB.ECOSPIRIN-GOLD (75-75-20)RT/HS TO BE CONTINUED TAB.METFORMIN 500MG RT/OD TO BE CONTINUED TAB.TELMA 40MG RT/OD TO BE CONTINUED TAB BISOPROLOL 2.5 MG RT/BD X 2 WEEKS TAB.STROCIT PLUS RT/OD X 2 WEEKS
TAB GABAPENTIN 150MG RT/HS X 1 MONTH TAB.DOLO 650MG RT/SOS ASEPTIC REGULAR DRESSING OF BED SORE WITH NEOSPORIN POWDER FOR L/A REGULAR PHYSIOTHERAPY OF LEFT UPPER AND LOWER LIMBS POSITION CHANGE 2ND HOURLY Follow Up FOLLOW UP TO GENERAL MEDICINE OPD AFTER 2 WEEKS/SOS When to Obtain Urgent Care IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
[15-06-2025 12.26] PPM 1: As mentioned in this week's clinical meeting archived here: https://pajrcasereporter.blogspot.com/2025/06/80f-puo-stroke-altered-sensorium.html?m=1, a syndromic approach is often applied to fever of unknown origin by hitting all possible organisms with potentially effective interventions (more often than we may like to admit or report).
By looking at the patient's fever graph can we figure out a causal correlation between which intervention was eventually responsible for stopping her fever?
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