35F with altered sensorium

A 35yr old female presented with complaints of vomitings 3 episodes 6 days back followed by altered sensorium . no h/o trauma no involuntary movements no h/o deviation of mouth no h/o fever,cough,chest pain,tremors,orthopnea,pnd no h/o use of anticoagulants,oral contraceptive pills past history: h/o intermittent headache. known case of tb 4yrs back ,took ATT for 6 months. no h/o HTN,DM,CVA,CAD,SIZURES. surgical history negative. General examination: Pallor present Icterus negative No cyanosis clubbing lymphademopathy,Edema. Mild dehydration and malnutrition present .Doll's eye postive Bp 100/60 mmhg Pr 110 bpm spo2 96% temp 102F RR 20cpm Grbs 119 gm/dl Cvs s1 s2 hears no murmurs Rs bae + nvbs hears P/a soft ,nontender,bowels sound heard, Cns HMF- patient unconscious stuporous speech- no response MMSE- not elicited cranial nerves-1st not elicited 2nd not elicited rt lf 3rd,4th,6th pupil size. N N DLR/CLR. N. N NO pstosis, nystagmus. 5th sensory not elicited motor not elicited reflex corneal normal,conjuctival normal 7th motor nasolabial fold normal no deviation of mouth sensory not elicited reflex corenal and conjuctival normal secretomotor moistness of eye and tongue normal,buccal mucosa normal 8 the nerve:Rinnes and Weber's not elicited 9and 10 th nerve: uvula centrally placed,gag reflex present 11 th nerve: trapezieus not elicited, sternocleidomastoid not elicited 12 th nerve: tongue tone normal, no wasting, no fibrillations,no deviation of tongue MOTOR SYSTEM Right. Left Bulk: normal. Normal Tone: ul. N/ decre. Normal LL. Decre. Normal Power not elicited. 3/5 both upper and lower limb Reflexes. Superficial reflexes Right. Left Corneal. P P Conjunctival P. P Abdominal. P. P Plantar increase. Withdrawal Deep tendon reflexes Right. Left Biceps. P. P Triceps. N. N Supinator. N. N Knee N. N Ankle. N. N Primitive reflex -absent Involuntary movements - absent ( chorea,ballismus - negative) but left lower limb continuous / intermittent movements positive gait SENSORY SYSTEM not elicited Pain present in all four limbs CEREBELLUM titubation - absent Nystagmus- absent Intensional tremors - absent Pendular knee jerk - absent Coordination test not done MENINGIAL SIGNS Neck stiffness - positive Kernigns sign - negative Brudzinkis sign - negative MRI WAS DONE WHICH SHOWED CAPSULOGANGLIONIC HAEMORRHAGE https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOMbkRi3Et2eFe9ewuMxT7kaoOabEQspU3hgZ_b2ZGp4JbHoFiuP2kdAmhFu_4WNobWT_pR6Bx6mku6vXVXTDLNsSD5zxGsFWGe6Rvl-5wTCGvl6OOT-ferfho6i7Ddtg911Bajg5tYL0/s1600/1590251276527314-0.png https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-fpPKbjw6t6pD9Q4cRWb8XzlSoaQqxu9yok7GyRMOUagkwnlNKgzBvvBrrP3m66TCCjQwUfrLkT95exeQBBBkkHD2EsS5jSv02_YAFwn6jXr4ihNRzvRYqoSA4HSv9EhE6SpypNKZf88/s1600/1590251271337516-1.png https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoLqYpCajGkNhnbcH4yF-lWMHme6J27k7LJTPVrCYrDL5COm7NTLbJCkPRsQ1IDalfuruEzB4oqYPrLakCjbZI5dUeTkj9kGHw68HZ5Df563_wMlFQbEZk8wgR-_oa3Vhpy_fljr1se5s/s1600/1590251219005168-2.png https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMUgfpiuNzJAaSK2xaAwi9-M5B_gWTZVZbh_g9hRaHvpgET164mU-wNA5XfazYBGdTggYEVFJnjpQnGejOwWgsBMO1EA75K9izCHMCyhcTSlKa_Yuy9AYSTu_Li79PSsGgPwFMC3QGc7I/s1600/1590251202070045-3.png https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjj3SGgyh_Z_-vvPV7R1IO1JHLIfVZlLfE1WRD9khul7nekNaZak8iQ5cNZnWXp0VYSyHrQ-6hi77DmRehppADyMKsYHyxJMjfEcLi-BsvieMHiQf1R2Qyn4cBzHN4V8xyi4ipBMkc2S3Y/s1600/1590251171067713-4.png Course in hospital:The patient was admitted in our ICU with high grade fever spikes and severe leucocytosis suggestive of sepsis along with a mass lesion and hematoma and she was empirically managed with iv antibiotics and her fever spikes and leucocytosis recovered. Her coma took a few more days to recover spontaneously and she was finally able to mobilize herself with persistent neurological deficits since last few days. She still has mutism due to an affection of the Broca's area (insert into the diagnosis) and possible other cognitive deficits yet to be ascertained. Psychiatry referral was done in view of cognitive function and higher mental functions According to informent :- C/o not talking only responding at times Stressors + (financial, family, personal) Crying spells + low mood+ ,she was active at work GAB patient is lying on bed unable to move her right arm and leg ETEC +, built not sustained PMA decreased Rapport could not be established SPEECH:not uttering words but responding to sounds at times non verbal communication +at times though a bit slow AFFECT: dysphoric Further MSE could not be elicited , Orientation could not be assessed Patient power gradually improved from 0/5 on right side to 3/5 and on left side from 3/5 to 4/5 INVESTIGATIONS HBS AG: negative ANTIHCV ANTIBODIES: nonreactive HIV : non reactive HEMOGRAM : 28/4 29/4. 1/5. 3/5 HB 5.4 6.3. 7.1. 9.4 Platelets 1.94. 0.31. 1.11. 1.5 TLC 12000 PT. 20. 16 INR. 1.7. 1.1 APTT. 34 BT. 10. 2 CT. 15. 4 TO.BIL. 1.03. 1.48 DI.BIL. 0.27. 0.33 SGOT. 17. 20 SGPT. 8.8. 12 ALK.PH. 68. 64 TO.PRO. 7. 7.1 ALB. 4.1 A/G RATIO. 1.37 RFT UREA. 17. 52 CREATININE. 0.89. 0.8 URIC ACID 2.6 CALCIUM. 10.5 PHOS. 4.2 SODIUM. 146 K+. 3.6 CL-. 100 2 packs of RDP and 1pack of PRBC transfused on 30/4/20 Diagnosis Cva with right sided hemiplegia acute haemorrhage involving left corona radiata and lentiform nucleus,internal capsule with intraventricular extension.secondary to ? AV malformations Acute hemorrhage with ?underlying mass lesion or abscesswith anaemia with old pulmonary Koch's, bed sore resolving ,pseudodementia ?Post stroke delirium TREATMENT 1) inj. Amikacin 500mg bd 2) inj ceftriaxone 2gm iv bd( both antibiotics were given for 7 days and as sepsis resolved they were de escalated) 2)INJ.Pantop 40 mg od 4) INJ.NEOMOL 1 g IV.( if temp is more than 102F) 5)TAB.PCM 650 mg RT TID 6) INJ.ZOFER 4mg IV.SOS 7)TAB.VITAMIN C 500 mg RT OD 8) TAB. B COMPLEX RT OD 10)TAB.EPTON 100mg RT BD ( Dose slowly tapered as not indicated in seizure prophylaxis in a patient with ICH) 11) SYP.LACTULOSE 10 ml RT TID 12) NEB WITH MUCOMIST 6 TH HOURLY followed by oral suctioning. 13) PROPPED UP POSITION 14) RT FEEDS 2ND HOURLY MILK 30ml 1 HOURLY WATER 150ml 15)I/O CHARTING 16)GRBS CHARTING 6TH HOURLY 17)BP ,PULSE ,SPO2 ,RRMONITORING 18) AIR BED 19)DVT STOCKING 20)FREQUENT CHANGE OF POSITION 2NDHOURLY 21) TEMPERATURE CHARTING 6th hourly. 22)T.FLUOXETINE 20 MG OD× 10 DAYS 23)T.DONAMEM 10MG OD× 10 DAYS 24) Air bed with frequent change of position 25)Bed sores dressing with neosporin powder for l/a 26) CHEST,UPPER AND LOWER LIMBS PHYSIOTHERAPY PROCEDURE 2D ECHO was done to a heart failure patient with tricuspid regurgitation And mitral stenosis. https://drive.google.com/file/d/1XVUkpLrBrsbNkFu-3xeB0Ia2JI9IgeCm/view?usp=drivesdk