CASE SUMMARY

Patient named Rattan Nagpal 64 year old female a k/c/o HTN and seizure disorder presented with h/o deviation of angle of mouth since today 3.30 pm of acute onset associated with difficulty in speech.She also gives h/o weakness in the right upper and lower limb of acute onset progressive in nature.Patient also gives h/o Severe headache and one episode of vomiting. O/E she was found to have elevated BP at 180/100 mmHg.Aphasia was present though she was conscious.

The power in Rt upper and lower limb was..Plantar response on the right side was extensor.She was initially taken to SGRH were CT brain was done Which showed Fronto-parietal bleed with mass effect. Patient was put on Inj Mannitol in BLK emergency and was shifted to MICU. Inj Lasix, Dexa, Aragon and strocit were started. Initial investigations showed raised TLC at 15500, Serum electrolytes,LFT were WNL.KFT were mildly deranged with creat-1.4 uric acid-7.6.

ECG showed occasional VPCs hence Beta Blocker Was started. ECHO was done which was non Contributory. .Inj Taxim was started Patient turned restless,irritable and Neurology opinion was taken on 9/10/11 and They advised CT angio of brain which was deferred as patient was very restless. Inj Nimodepin was 60mg TDS and NTG infusion were started to maintain BP at Systolic 150 mmHg.

On 10/9/11 Patient turned febrile , TLC-raised to 23500 though serum electrolytes were WNL. Blood and urine cultures were sent and antibiotics were modified to Inj Dalacin. As patient continued to deteriorate with worsening Sensorium, repeat CT Brain was done which didnt show any marked variation from previous CT brain Findings .Inj Dexa stopped and Inj Mannitol was w/h. Patient deterioted further on 11/9/11, with drowsiness increasing patient not responding to commands, pre-renal azotemia and CXR showing Rt LZ haziness.

At 6.20 pm patient started desaturating ABG done showed Hypoxemia hence was intubated.Previously sent cultures were found to be sterile.ET tube secretions were sent for c/s and on 13/09/11 it came positive for MRSA.Inj Lenozolid was added.Counts and KFT showing improvement.On 15/9/11 Patient developed fluctuating BP which was confirmed by manual assessment requireing Noradrenaline on & off, ECG done s/o AF and PVR and Inj Cardarone infusion started with cardiology opinion. On 16/09/11 TLC again raised to 18200

and KFT deterioted.Repeat CXR showing Rt LZ haziness . Blood c/s and Urine c/s were sent.on 18/9/11 Blood culture came positive for Pseudomonas auriginosa and urine culture showed growth of E Coli (ESBL +ve).Inj Meropenam were added based on senistivity reports. In view of raising s.urea and creatinine levels dialysis was done on 17/9/11. Patients sensorium started improving on 18th and 19th and counts ands renal parameters started improving.Inj Dalacin and Linid were stopped on 19/9/11.

MRI brain done on 19/9/11 was s/o early subacute hematoma in Lt gangliocapsular region and adjacent temporal lobe.small subacute infarct in medial Lt temperooccipetal lobe.Repeat ET tube c/s was done on 21/9/11 which showed Burkholderia cepacia and Inj Aztreonam was added to the treatment.Patient was monitored continuously with expert advice from nephrologist and neurologist.Gradually patients sensorium improved over the next 4 days and he was extubated on 24/9/11.

All the vital organs parameters were improving incluiding KFTs,Electrolytes and others.Patient again developed fever on 28/9/11 and Inj Fluconozole was started sending repeat blood culture and it showed growth of candida tropicalis and hence flucanozole was replaced with voraconazole.With improvement in condition patient was moved to wards on 1/10/11.Patient was continued on conservative medications and gradually shifted over to oral antibiotics and was discharged on 12/10/11 in stable condition.