A 56 YEAR OLD MALE WITH ? SYNCOPE(OLD CVA WITH QUADRIPARESIS)

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A 56 yr old male farmer by occupation, resident of narketpally, came to the casualty with c/o loss of consciousness for 5 mins( around 9 am) on 28/8/21, and fever since 3 days.

The pt was apparently asymptomatic 10 years back, and then developed sudden onset of weakness of left UL &LL , for which he was hospitalized for 8 to 10 days, resumed his works after 1 month.
since then patient complaints of mild left LL weakness.

10 days back at around 10 am near fields patient passed urine and was about to get up , bt experienced giddiness and fell down , sustained injury over left half of face and over right knee, received injections from local RMP, no vomiting, no headache.

yesterday pt developed fever- low grade, bt didn't consume food yesterday.
pt also have cold and dry cough.
Today morning @5 am pt got up to pass urine in bathroom, he had shivering, giddiness and sweating, he had uprolling of eyeballs,no involuntary movements,no frothing, no tonic movements, no involuntary micturition / defecation.
they immediately called local RMP and then referred here.
patient on presentation had hypotension, SBP 70 mmhg.

PAST HISTORY: NO DM,HTN,Asthma, epilepsy,CAD,
k/c/o CVA since 10 yrs. 

On examination:
Temp- afebrile.
PR:67 BPM.
RR: 25 CPM.
SBP: 90/60 mmhg 
Spo2 : 98%
GRBS 151 MG%.

No pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema.

CVS:S1 S2 HEARD, NO MURMURS.

RS: NVBS heard, BAE +, TRACHEA CENTRAL.

P/A : SOFT, NON TENDER, NON DISTENDED.

CNS: CONSCIOUS, Speech normal, NO SIGNS OF MENINGEAL IRRITATION.

POWER RT.        LT.
        UL.  5/5       4/5
        LL.  5/5.        5/5

REFLEXES.
                   RT.             LT.
BICEPS.     +3                 +3
TRICEPS.    +3                +3
SUPINATOR. +3              +3
KNEE.              +  3          +3
ANKLE.            + 3          +3
PLANTAR: EXTENSOR left side.

INVESTIGATIONS
28/8/21

29/8/21

30/8/21

31/8/21

Clinical images
 Anisochoria
Pinpoint pupil in R eye
Dilated pupil in L eye
OPHTHAL REFERRAL



TREATMENT
28/8/21 1pm
Diagnosis
? Syncope
Old CVA left Hemiparesis
Acute kidney injury

O/E
Pt is C/C/C
BP:80/60mmhg
PR:60bpm
RS :BAE+
CVS:S1,S2 heard.

Rx
IVF 3 UNIT NS bolus, NS @ 100ml/hr 
Inj.PANT OP 40mg IV/OD
Inj.NORAD @ 4ml/hr increase or decrease to maintain MAP> 65mm hg
Hrly BP, PR, RR monitoring
Strict I/O monitoring


SOAP NOTES DAY 1(29/8/21)
Subjective
No fresh complaints

Objective
BP: 90/70 mm hg
PR :58bpm
TEMP: Afebrile
GRBS: 110mg/dl
SPO2: 97% at room air
Stools: not passed, flatus+
Cvs: S1 S2+,no murmurs
RS: BLAE+,NVBS,No added sounds
P/A : soft.

CNS: Oriented to T/P/P
memory: Intact
HMF: normal
Sensory system: Normal.
Motor tone: Normal
Power.  R.        L
    U/L.  5/5.     4/5
    L/L.   5/5.      4/5
Pupils.               
        Rt: Pinpoint. Lt: Dilated.

REFLEXES
        RT.               LT.
B- 3+                   3+
T- 3+                    3+
S-. -                       -
A- 2+                    2+
K- 3+                    3+
P-FLEXION.    FLEXION.

Assessment
? SYNCOPAL ATTACK
OLD CVA LEFT HEMIPARESIS

Plan of care
IVF NS,RL @ 100ml/hr 
Inj.PAN 40mg IV/OD
Inj.NORAD @4ml/hr increase or decrease to maintain MAP> 65 mmHg
BP,PR,RR monitoring hourly
TEMP 4th hourly monitoring
Strict I/O  charting.

Day 2
A 56 YEAR old male with ? SYNCOPAL ATTACK 

Subjective
No fresh complaints

Objective
pt is c/c/c
BP:120/80 mm hg
PR :84 bpm
Temp : afebrile
Spo2:  97%

Assessment
? SYNCOPAL ATTACK
OLD CVA left Hemiparesis

Plan of care
IVF NS,RL @ 100ml/hr.
PAN 40 mg IV OD
BP,PR,RR,SPO2 monitoring
Temp monitoring 4th hrly
I/O charting
Soap notes

Day 3
A 56 YEAR old male with ? SYNCOPAL ATTACK 

Subjective
Pt complains of fever.

Objective
pt is c/c/c
BP:120/80 mm hg
PR :64 bpm
Temp : afebrile
Spo2: 97%

Power Rt.       Lt
U/L.     4/5.     4/5
L/L.      4/5.     4/5.

Upper limb Hypertonia.

Assessment
? SYNCOPAL ATTACK
OLD CVA with Quadriparesis
Viral pyrexia with thrombocytopenia

Plan of care
IVF NS,RL @ 100ml/hr.
PAN 40 mg IV OD
BP,PR,RR,SPO2 monitoring
Temp monitoring 4th hrly
I/O charting

Soap notes
Day 4
A 56 YEAR old male with ? SYNCOPAL ATTACK 

Subjective
Pt complains of cough ass with sputum since yesterday 
No fever spikes
No stools passed

Objective
pt is c/c/c
BP:120/70 mm hg
PR :80 bpm
Temp : afebrile
Spo2: 97%
RR: 

Assessment
? SYNCOPAL ATTACK
OLD CVA Quadriparesis
Thrombophlebitis

Plan of care

IVF NS,RL @ 100ml/hr.
PAN 40 mg IV OD
Syp. Ascoryl 15ml po/TID 
BP,PR,RR,SPO2 monitoring
Temp monitoring 4th hrly
I/O charting

http://keerthykasa80.blogspot.com/2021/08/a-56-year-old-male-with-syncope.html

Day 5
Subjective:
Cough decreased 
stools passed

Objective
pt is c/c/c
BP:120/80 mm hg
PR :70 bpm
Temp : febrile(100F)
Spo2:  97%

Assessment
? SYNCOPAL ATTACK
OLD CVA Quadriparesis
?TRAUMATIC INDUCED MYDRIASIS 

Plan of care
TAB. PAN 40 mg OD
Syp. Ascoryl 15ml po/TID 
TAB. DOLO 650mg po/tid
BP,PR,RR,SPO2 monitoring
Temp monitoring 4th hrly

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