70yr old male presented with altered sensorium
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Case :
Patient was apparently alright 10days back, when he complained of vision loss and headache. Patient previously was having blurring of vision, but 10 days back he complained sudden loss of vision and headache, so they when to a local hospital and got evaluated. There a CT BRAIN was done, which was normal according to the patient attenders ( reports unavailable )
Patient continued to do his regular activity and was alright untill today evening - after having his dinner, patient had 2 episodes of vomiting associated with nausea, containing food particles and not blood tinged - No h/o weakness
Following which, patient was in altered state and not responding to commands
No h/o involuntary movements, trauma to head, Fever, cough, SOB
No h/o pedal edema, decreased urine output and loose stools, pain abdomen
Patient was unable to swallow and drooling of secretions present
He is not a k/c/o diabetes mellitus, hypertension, asthma, CAD, CVA
Patient took COVID vaccination 1 month ago ( 1st does )
He underwent hernia surgery 20 years ago
Patient is an occasional alcoholic and chronic beedi/ chutta smoker
On examination
Patient is consciousness, coherent, cooperative
No Pallor, icterus, cynaosis, clubbing, lymphadenopathy, edema
VITAL
Temp - Afebrile
BP - 130/90 mmHg
PR - 100 bpm
RR - 22 cpm
SpO2 - 90% at RA
GRBS - 111 mg/dl
CVS - S1 S2 heard
RS - BAE present, B/L coarse creations present in all areas
Per Abdomen - soft, BS +
CNS -
GCS - E1V1M2
On deep pain - extension present
Pupils - B/L constricted, not reacting to light
Power could not be elicited
Tone :
Right Left
Upper limb - Increased Increased
Lower limb - Normal Normal
Reflexes :
Right Left
Biceps - 2+ 2+
Triceps - 1+ 1+
Supinator - - -
Knee - 2+ 2+
Ankle - 4+(clonus) 4+(clonus)
Plantar - Mute Mute
No meningeal signs present
Cerebral sign could not be elicited
Provisional diagnosis :
Altered sensorium due to ? Acute ischemic CVA (? Pons / ? Left old occipital infract )
Type 1 Respiratory failure with ? Aspiration pneumonia
INVESTIGATIONS:
Hemogram
Hb - 12.7
TLC - 12300
PCV - 36.1
RBC - 4.17
PLT - 2.18
Blood grouping and typing - B positive
CUE
Albumin - +
Sugar - Nil
RBC - nil
Pus cells - 3-4
Epithelial- 2-4
RBS - 109
LFT
TB - 1.2
DB - 0.32
AST - 46
ALT - 22
ALP - 142
TP - 6
ALB - 3.5
RFT
Urea - 23
Creatinine - 1.1
Uric acid - 6
Ca - 9.8
P - 2.0
Na - 136
K - 3.7
Cl - 97
ABG ( before intubation )
pH - 7.4
pCO2 - 22.6
pO2 - 59
HCO3 - 15.4
St HCO3 - 19.4
ABG ( after intubation )
pH - 7.1
pCO2 - 54.4
pO2 - 103
HCO3 - 18.7
St HCO3 - 16.3
ECG
CT Brain
Chest X ray AP view before intubation
Chest X ray ap view after intubation
Treatment
- Propped up position
- Air water bed
- IVF - 1 NS, 1 RL at 100ml/hr
- Inj. PIPTAZ 4.5g IV STAT
- Inj. PAN 40mg IV OD
- Inj. ZOFER 4mg IV BD
- Tab. PCM 650mg RT SOS
- Neb. with DUOLIN- 8th hourly, BUDECORT- 12th hourly, MUCOMIST - 8th hourly
- Ryles feeding - milk + protein powder, water 4th hourly 100ml
- T. ECOSPIRIN-AV (150/40 mg ) / RT / HS
- Inj. MIDOZOLAM @2ml/hr
Death summary
He is 70 year old male presented to casualty in comatose state with GCS 4/15 ( E1V1M2), farmer by occupation, with h/o vision loss and headache 10days ago, he went to local hospital, CT Brain was done and was normal until yesterday evening. He had 2 episodes of vomiting a/w nausea. Following, patient was in altered state and was not responding to commands. CT Brain was done showing B/L occipital lobe infracts i/v/o GCS (3/15) and patient gasping with aspiration of food particles secretions. Patient was planned for elective intubation and was incubated with 7mm ET tube. Around 4:35 pm due to absent Pulse and BP not recordable. CRP was started according to acw guidelines. Despite the above resuscitation efforts, patient could not be revived and was declared dead on 24/9/2021 at 5:06pm
Immediate cause of death : cardiac arrest secondary to B/L occipital lobe infracts with type 1 Respiratory failure
Antecedent cause of death : Altered sensorium secondary to B/L occipital lobe infracts with h/o chronic smoker
