Concluded Case

LEFT SIDED NEUROLOGICAL DEFICIT,SOB AND CHEST DISCOMFORT

60yrs/M known CAD with CMP(EF -20%) with HTN presented with left sided weakness with slurred speech and mouth deviation to left side with Breathlessness and chest discomfort.O/e - BP - Not recordable,Cold peripheries ,out put nil,CNS - Conscious, oriented,left sided weakness(UL more than LL),Plantars-B/l upgoing,PR - 110/mt,Spo2 - 88%,RR -42/Mt,Lab report enclosed INTERPRET ECG,CT SCAN HEAD AND ABG AND SUGGEST TREATMENT PLAN?

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Concluded answer
CT shows - Right watershed Infarct CXR - Cardiomegaly ECG - Junctional escape bradycardia(rate - 50-65),wide QRS,Peaked T and ST elevation S/o Hyperkalemia but can't R/o STEMI. ABG - Respiratory acidosis, chemistry - Hyperkalemia, hyponatremia and renal failure. Patient managed with Antibiotics,inotropes and Bipap support with supportive treatment.
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THANKS Dr Prashant Ved for tagging me . It is really an interesting case which needs discussion. Main signs and symptoms and investigations reveal many aspects 1.A right watershed cerebral infarct - As per the CT findings of infarct - the effects of watershed infarcts are far more than simple infarct because actual infarction site can be localised far away from the infarct .The watershed area , in this case looks like a cortical watershed , is itself susceptible to global ischaemia as the distal nature of vasculature predisposes to most sensitive to profound hypo perfusion. 2.The,signs and symptoms of left sided weakness, BP - not recordable , favour watershed infarction . 3.X- ray chest shows right apical fibroectatic lesions with, COPD- emphysema and tracheal pull towards right side . 4.Acute renal failure with significantly raised Urea and creatinine and hypovolemic shock 5.Hyperkalemia and bradycardia- embolism in cerebral infarct is most likely of cardiac origin . 6.A combination of respiratory and metabolic acidosis due to COPD and hypovolemia . Treatment Plan . 1.Start Atorvastatin 40 mg + aspirin 150 mg + clopidogrel 150 mg through ryle tube or orally if patient is fully conscious. 2.IV fluids- preferably R.L , 5% Dextrose + DNS as per the Nephrologist and cardiologist opinion. 3.Correction of acidosis, hyperkalemia 4.Involve a pulmonologist, cardiologist, neurologist and cardiologist in the treatment plan 5.Parenteral antibiotics and maintain input output after catheterisation
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Rt parietal infarction seen. Cxray shows rt apical fibrobronchiectatic lesions with tracheal pull towards right. Bil hyperinflation sugg of COPD emphysema. ECG bradycardia, nodal rhythm, Poor progression of R waves in anterolateral leads. ARF, hyperkalemia. Resp acidosis.
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Acute ischemic infarct start on stroke protocol if window is not kissed then give Rtpa else start on dual antiplatelets plus statins check for vitals continuously and get necessary lab work done. involve cardiologist and pulmonologist for further evaluation
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Rt Cerebral Ischaemic stroke parietal region Rt Apical fibronodular consolidation with Emphysema RMD, Hypokalemia Start aspirin Clopidogrel atorvastatin Epsolin (precautionary) Go for ECHO
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Rt watershed infarct with dcmp with ?Copd ?Rt pneumothorax Get pulmonary and cardiology opinion If required get rt chest tube, icu management Multisystem involvement
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CT shows - Right watershed Infarct CXR - Cardiomegaly ECG - Junctional escape bradycardia(rate - 50-65),wide QRS,Peaked T and ST elevation S/o Hyperkalemia but can't R/o STEMI. ABG - Respiratory acidosis, chemistry - Hyperkalemia, hyponatremia and renal failure. Patient managed with Antibiotics,inotropes and Bipap support with supportive treatment.
Embolic Stroke Do an ECHO and start antiplatelet, anticoagulation as well as antilipids
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Acute infarct right parietal involving basal ganglion with hypoxic anoxic changes
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@Parveen Yograj sir,@Dr. Yashesh Dalal sir
Agreed with Dr.Sandeep G