Case 1 Hemiplegia with aphasia

8/2/2019 Case 1 Hemiplegia with aphasia

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CASE SUMMARY

Patient named Rattan Nagpal 64 year old female a k/c/o HTNand seizure disorder presented with h/o deviation of angle ofmouth since today 3.30 pm of acute onset associated withdifficulty in speech.She also gives h/o weakness in the right

upper and lower limb of acute onset progressive innature.Patient also gives h/o Severe headache and oneepisode of vomiting.

O/E she was found to have elevated BP at 180/100

mmHg.Aphasia was present though she was conscious.


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The power in Rt upper and lower limb was..Plantar

response on the right side was extensor.She was

initially taken to SGRH were CT brain was doneWhich showed Fronto-parietal bleed with mass

effect. Patient was put on Inj Mannitol in BLK

emergency and was shifted to MICU.Inj Lasix, Dexa, Aragon and strocit were

started. Initial investigations showed raised TLC at

15500, Serum electrolytes,LFT were WNL.KFT were

mildly deranged with creat-1.4 uric acid-7.6.


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ECG showed occasional VPCs hence Beta

Blocker Was started. ECHO was done which

was non Contributory..Inj Taxim was started Patient turned

restless,irritable and Neurology opinion was

taken on 9/10/11 and They advised CT angio of

brain which was deferred as patient was very

restless. Inj Nimodepin was 60mg TDS and NTG

infusion were started to maintain BP at Systolic

150 mmHg.


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On 10/9/11

Patient turned febrile , TLC-raised to 23500 thoughserum electrolytes were WNL. Blood and urine

cultures were sent and antibiotics were modifiedto Inj Dalacin.

As patient continued to deteriorate with worsening

Sensorium, repeat CT Brain was done which didntshow any marked variation from previous CT brain

Findings .Inj Dexa stopped and Inj Mannitol wasw/h. Patient deterioted further on 11/9/11, withdrowsiness increasing patient not responding tocommands, pre-renal azotemia and CXRshowing Rt LZ haziness.


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At 6.20 pm patient started desaturating ABGdone showed Hypoxemia hence wasintubated.Previously sent cultures werefound to be sterile.ET tube secretionswere sent for c/s and on 13/09/11 it camepositive for MRSA.Inj Lenozolid was

added.Counts and KFT showingimprovement.On 15/9/11 Patientdeveloped fluctuating BP which wasconfirmed by manual assessment

requireing Noradrenaline on & off, ECGdone s/o AF and PVR and Inj Cardaroneinfusion started with cardiology opinion.On 16/09/11 TLC again raised to 18200


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and KFT deterioted.Repeat CXR showing Rt LZhaziness . Blood c/s and Urine c/s were

sent.on 18/9/11 Blood culture came positivefor Pseudomonas auriginosa and urine cultureshowed growth of E Coli (ESBL +ve).Inj

Meropenam were added based on senistivityreports. In view of raising s.urea andcreatinine levels dialysis was done on 17/9/11.Patients sensorium started improving on 18th

and 19th and counts ands renal parametersstarted improving.Inj Dalacin and Linid werestopped on 19/9/11.


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MRI brain done on 19/9/11 was s/o earlysubacute hematoma in Lt gangliocapsular

region and adjacent temporal lobe.smallsubacute infarct in medial Lt tempero-occipetal lobe.Repeat ET tube c/s wasdone on 21/9/11 which showed

Burkholderia cepacia and Inj Aztreonamwas added to the treatment.Patient wasmonitored continuously with expert advicefrom nephrologist and

neurologist.Gradually patients sensoriumimproved over the next 4 days and he wasextubated on 24/9/11.


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All the vital organs parameters wereimproving incluiding KFTs,Electrolytes andothers.Patient again developed fever on28/9/11 and Inj Fluconozole was startedsending repeat blood culture and itshowed growth of candida tropicalis and

hence flucanozole was replaced withvoraconazole.With improvement incondition patient was moved to wards on1/10/11.Patient was continued on

conservative medications and graduallyshifted over to oral antibiotics and wasdischarged on 12/10/11 in stable condition.

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Case 1 Hemiplegia with aphasia