57 yr old male with cervical and lumbar spondylosis and acute ishaemic stroke and with respiratory distress
57 yr old male with cervical and lumbar spondylosis and acute ishaemic stroke and with respiratory distress
NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT
A 57 yr old male resident of Nalgonda security guard in a bank in Nalgonda came with chief complaints of fever since 1month and altered sensorium 1 month back and shortness of breath since 6days
HISTORY OF PRESENT ILLNESS:
He is apparently asymptomatic before 5yrs then he developed neck pain and backache which are insidious in onset gradually progressive dragging type associated with muscle spasms and clicking, popping sensation in the neck and shock like pain on the back and not able to get up from bed and radiating towards the both lower limbs and then after he developed dizziness, tingling and numbness in both the hands and legs and loss of bowel and bladder control. Bowel was cleared through enema and bladder by urinary catheter. For the above complaints it is diagnosed as cervical spondylosis with cervical myelopathy and lumbar spondylosis. For cervical spondylosis and myelopathy cervical repair and platting was suggested to the patient and it was done. For lumbar spondylosis it is conservatively managed with medicines may be using NSAIDS, corticosteroids, opioids. Recently he developed with generalised weakness since 1month with blurring of vision which was insidious in onset gradually progressive and after 2 days he developed fever which was 103 degrees F which is insidious in onset gradually progressive with no aggravating and relieving factors known. After 2days of onset of fever he suddenly fell in bathroom due to weakness in legs and hurt his head and also developed slurring of speech. He was then taken to a private hospital where his condition worsened and was unable to remember things which happened 10 mins back and could not recognise anyone except his elder daughter. As he was being taken to MRI, he lost consciousness and completely stopped responding. MRI was taken and high dose antibiotics were given where he regained consciousness and could slowly start recognizing his family members. There he was treated strong enough to transport to our hospital. They did an elective tracheostomy and sent him to our hospital. Upon reaching our hospital CSF analysis were done and treatment was started. Fever subsided completely and he was afebrile for a week. After a week into the treatment, he developed shortness of breath which was grade 2 mMrc initially and progressed to grade 4 mMrc, he started developing pneumothorax to which a inter coastal drainage tube was placed. He was on ventilator for some time after this episode. Later 3 days after pneumothorax the patient developed a bed sore and along with-it developed fever. This time it was continuous gradually progressive relieved on medication. No history of loss of coordination and unsteadiness while walking. No history of nausea, vomiting, diarrhoea, constipation abdominal pain. No h/o decreased in urine, blood in urine, pus in the urine.
PAST HISTORY:
No h/o diabetes, asthma, TB, coronary artery disease in the past.
PERSONAL HISTORY:
His occupation is security guard in a bank and ATM in Nalgonda; sits in a chair for a long time.
Diet: mixed
Appetite: normal
Sleep: regular
Bowel and bladder movements: irregular
No h/o smoking, chewing tobacco
H/o toddy intake
FAMILY HISTORY:
No relevant family history
Treacheostomy
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative. moderately built and nourished
Pallor - present
No icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.
Vitals:
Temperature: 103 F
Blood pressure:130/90 mmHg
Pulse rate: 96 bpm
Respiratory rate: 24 cpm
FEVER CHART:
SYSTEMIC EXAMINATION
RESPIRATORY EXAMINATION
Inspection:
Position of trachea seams to be central
chest b/l symmetrical
bilateral air entry is normal with tracheostomy and ventilation but decreased with removal
no scars and sinuses on the chest wall
no chest wall deformities
no visible pulsations over the chest
Palpation:
all inspiratory findings are confirmed
tactile focal fremitus: decreased on right mammary, infra-axillary, infra-scapular, inter-scapular areas
Percussion:
Dull note in right mammary, infra-axillary, infra-scapular, inter-scapular areas. and resonant note in left infra-axillary, infra-scapular regions.And fine crackles in the left infra-clavicular and mammary regions.
Auscultation:
Decreased breath sounds in right and left infra-axillary, infra scapular regions.
CENTRAL NERVOUS SYSTEM EXAMINATION
Higher mental functions: Intact
CRANIAL NERVES
Olfactory: Normal
Optic: Normal
Oculomotor, trochlear and abducens: Normal
Trigeminal: Normal
Facial: Normal
Vestibulo-cochlear: Normal
Glossopharyngeal, vagus: Normal
Spinal accessory: Normal
Hypoglossal: Normal
MOTOR FUNCTIONS
Bulk: Normal in all four limbs
Tone: Normal in all four limbs
Power: Upper limb left 4/5, Upper limb right 4/5
Lower limb left 4/5, Lower limb right 4/5
Neck muscles good
Trunk muscles good
Plantar reflex present on both sides
Reflexes: Superficial reflexes: Corneal, conjunctival, pharyngeal, abdominal and plantar reflexes : Present
Deep tendon reflexes: Biceps reflex 2+ on both sides
Triceps reflex 2+ on both sides
Supinator jerk 2+ on both sides
Knee jerk 2+ on both sides
Ankle jerk 2+ on both sides
Coordination tested along with cerebellum normal
No involuntary movements
SENSORY SYSTEM
Spinothalamic: Crude touch, pain, temperature normal on both sides on all limbs
Posterior column: Fine touch, Vibration, Position sense present on all limbs
Cortical: Two-point discrimination, Tactile localisation, Graphesthesia, Stereognosis normal
CEREBELLAR SIGNS
No nystagmus, coordination intact in upper and lower limbs, hypotonia absent
Finger nose test normal
Heal knee test normal
Dysdiadokinesia: negative
ROMBERG sign normal
NO SIGNS OF MENINGEAL IRRITATION (Neck stiffness, kernig’s sign, Brudzinski sign)
No thickened nerves in periphery, trophic ulcers, wrist drop or foot drop
CARDIOVASCULAR EXAMINATION
S1, S2 heard. No murmurs
ABDOMEN
Abdomen is soft, non-tender, no organomegaly
PROVISIONAL DIAGNOSIS:
Acute ischeamic stroke involving cortical and subcortical regions with quadriparesis with type 2 respiratory failure secondary to anemia and Grade 4 bed sore and with previous history of cervical spondylosis with myelopathy and lumbar spondylosis.
INVESTIGATIONS:
Suggestive of respiratory acidosis which is uncompensated
