DISCHARGE SUMMARY

DEPARTMENT OF NEUROLOGY
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH
CHANDIGARH – 160012
Vasudev singh
NAME AGE 65 SEX MALE
thukral
FATHER’S/
ADMISSION
HUSBAND’S kirpal singh CR NO 201802025063 2022022151
NO.
NAME
ADDRESS sector 15 chandugarh CONTACT NO. 9814015163
DOA 05-04-2022 DOD 15-04-2022 CONSULTANT Prof V Lal
CAA-ri (possible)
DIAGNOSIS
ILD

CHIEF COMPLAINTS:
Recurrent CVA since 2020
Cognitive disturbances since 2020
BGH AND HOPI:
patient was in his usual state of health till march 2020 then pateint developed acute onset of confusion in
the form of difficulty in naming and inability to recognise friends and family . Next day morning he
noticed that he had bilateral diminission of vision when he could not read the newspaper , but his vision
improved over 2 days but difficulty in naming persisted and he has difficulty in doing transactions , ,
emotional liability and h/o confabulation .Patient used to have morning things confusion and difficult in
identifying family members, difficulty in recommitting route from and to workplace . then patient
improved over the next 1 month and he became independent in all aspects of daily life except in difficulty
in naming and decreased social interaction and anger issues
31/4/2021:-patient received first dose of moderna vaccine on 30/3/2021,2 days later he developed early
morning headache , frontal in location , throbbing type,VAS score of 6/10 with nausea and vomitting along
with acute onset confusion and decreased speech output , he was taken to a private hospital and Imaging
was done which shows left frontal lobe bleed and antiplatelets were stopped and he was managed
conservativly. 2 months later later he had transient weakness of left UL along with facial deviation to right
side , CT brain showed no infarct but ther is a snall volume acute SAH overlying the right fronto parietal
region
and on further evaluation with MRI on 7/4/22 which showed scattered areas of hemorrhage within the
cerebral hemispheres most pronounced in the left frontal lobe most pronounced in the left frontal lobe
associated with trace SDH as well.
His Coginitive disturbance during the next 1 year continued to worsen such that he had difficulty in
planning and inattention of ADL such as bathing, wearing clothes . He had also had difficulty in trending
immediate events such he uses to forget what he had in the breakfast and repeatedly asking for the
Samething.His had mood changes with occasional anger outbursts and decreased socialization . his
confabulation episodes continued and he had also thoughts of people visiting to destroy his career and
future .
Then he had delusions of persecution and had episodes of panic attacks
He has lost interest in surroundings, and stopped doing prayed which he used to do, and he used the
decided attention span while interacting with his family members where he used to lost in the conversation.
No h/o any sleep disturbances or abnormal movements in the sleep
No h/o any hallucination or illusion and he was prescribed Coginitive training but his wife reports
minimal improvement after that.
3/04/2022:- patient had h/o headache , which is frontal in location, moderate in severity ,VAS score of
2/10.Not a/w nausea or vommiting , no h/o photophobia or phonophobia. at the same time patient ℅
backpain he also had h/o confusion in the form of not recognising his wife and daughter and NCCT done
at that time showed left temporal horn bleed with third ventricles extension.
Past History:
K/c/o ILD since 2017 and on wysolone
H/o DVT in 2017 and since then patient is on Rivoraxaban
H/O recurrent CVA
no h/o DM,HTN,CAD
FAMILY H/O:-

Personal history: mixed diet

No addictions, Normal appetite, Normal bladder, bowel habits
Sleep-normal

GENERAL PHYSICAL EXAMINATION ON ADMISSION:

Patient is conscious, oriented, responding to verbal commands
Vitals :
Pulse: 90/min, regular, all peripheral pulses are palpable
BP: 140/60 mmHg,
RR: 14cpm
SpO2: 95% @RA;
There is no icterus/lymphadenopathy/cyanosis /clubbing/pallor/edema
presence of purpuric lesions over the plantar aspect of left for ? digital ulcers over the 2nd toe of foot .
3*3cm purpuric lesion on the lateral aspect of right thigh

SYSTEMIC EXAMINATION
CVS- JVP- not elevated, s1, s2 normal. No murmur
RS- vesicular breath sounds
GI- no hepatosplenomegaly
HMF : Language normal , spontaneous speech normal, fluency reduced, comprehension present , repetition
normal,naming and word finding normal , reading normal , reading comprehension normal.
MMSE 12/30
Lobar function tests:
Frontal lobe:
1.Digit span forward 5 , backward 4
Trial making test A and Test B impaired.
Sequencing :Motor Luria -cannot perform 3 consecutive series even with examiner
Graphic Luria impaired,verbal similarities test impaired, verbal fluency impaired- zero words in 60 seconds
Conflicting instructions>2 errors. Inhibitory control go-no – go >2 errors, prover interpretation -was given 5
commonly used Punjabi proverbs – could interpret only 1 proverb . Judgment – preserved , insight – not
present .
Temporal Lobe :
Orientation : only to time and floor , person is present
Remote memory : personal information he could remember where he is born , and whats his DOB , and first
school , could not remember where is his house , work place or date of marriage and he could remember
only few historical facts .
New learning ability : impaired at 5 min, 10 min , 30min . visual memory impaired
Parietal lobe :
Simultaneous bilateral stimulation by visual , tactile and auditory preserved
Visual target cancellation: line bisection normal, word cancellation impaired
Simultagnosia: could recognize most of A letters except 1 and also marked V in place of A
Apraxia: pantomiming a task :preserved
Imitating the examiner: preserved
Tasks with real objects preserved
Constructional ability : 2 dimensional figures reproduced
3 dimensional figures : not reproduced
Clock drawing impaired

Calculation :verbal simple , verbal complex, and written complex all are impaired
Right -left orientation: impaired
Finger agnosia : nil
Geographic orientation impaired
Cortical sensation :
Stereognosis: unable to name
Graphesthesia :unable to name
2 point discrimination present
Occipital lobe
No prosopagnosia or visual object agnosia
CRANIAL NERVE:
II- VA- RT eye 6/9 LT eye /9 with correction
Pupils- 3 mm b/l, direct and indirect pupillary reflexes +
Fundus – bilateral normal, NO RAPD
III/IVVI movements are equal in all cardinal gazes
Normal saccades and pursuits
V- Normal, corneal reflex +, jaw jerk absent
VII: Normal
VIII- Weber’s centralized, AC>BC both ears, IX/X- uvula central, gag reflex normal
XI/XII-head turning normal

MOTOR SYSTEM EXAMINATION

Inspection:

Bulk:
Bilaterally normal
Tone:normal
Power: UL LL
Rt 5/5 5/5
Lt 5/5 5/5

DEEP TENDON JERKS: B T S K A

RIGHT 2+ 2+ 2+ 2+ 2+
LEFT 2+ 2+ 2+ 2+ 2+
B/l Plantar – RIGHT- Flexor
LEFT-flexor
SENSORY EXAMINATION:
Touch- normal
Pain- normal
Vibration:- normal
JPS- normal
Romberg- negative
Cerebellar examination – normal
INVESTIGATIONS:

Investigation 06/04/22 09/04/22

CBC 13.4/6300/147000 12.0/5100/13600

SE 139/4.9/105 136/3.6/102

RFT 28/0.89 24/1.08

OT/PT/ALP 33/41 28/43/107

TP/ALB 6.5/3.6 6.59/3.54

TB/CB 0.48/0.05 0.57/0.30

PT/APTT/PTI/INR 11.4/28/100/0.98
 Homocysteine 12.87micromol/L

chol/LDL/HDL/TG 116/57/50/86
TSH/T4/T3/TPO-3.73/6.09/0.95
HbA1c-6.3
ANA/ANCA-negative
Procoagulant workup- report awaited
FNAC FOR AMYLOID-Negative
DSA(789/22)(14/4/22):-
Report
Normal study
Csf study :

COURSE AND MANAGEMENT:

65 year old male has presented with above complaints of recurrent CVA since 2020 with recurrent
headache and confusionin each episode of CVA as mentioned in the history since 3 years and on each
evaluation has cortical bleeds on CT brain and has progressive cognitive decline predominantly affecting
fronto- temporal as well as parietal cognitive function and he had been admitted for evaluation of recurrent
cortical bleeds and basic evaluation was done with CBC , Coagulogram , LFT and RFT , all were within
normal limit and other possibilities of vasculitis such as primary angiitis of the CNS , sarcoidosis were
considered and evaluated with MRI brain with vessel wall agiogram which showed SAH in left temporal
lobe and chonic hemorrages win left fronto-temporal lobe and IVH in b/l occipital horns , multiple
microhemorrahges in bilateral cerebral hemispheres , with normal angiogram study and DSA of cerebral
vessels a normal study , with clinical features of headache , decrease in consciousness , behavorial changes
as well as radiological features of subcortical white matter changes as well as microhemorrhages in the
cortex as well as subcortex along with macro bleed , a possibility of CAA-related inflammation/beta
amyloid angiitis was considered and a trial of steroids was given after ruling out CNS infection and is being
discharged with following advice

ADVICE ON DISCHARGE:

To follow up in Neurology OPD on Mon / Wed / Fri after 2 weeks with procoagulant work up reports , fbs
, ppbs

Dr. SOURISH Dr. PADMA Dr. MANOD PROF V LAL/DR.JITUPAM

BED JR BED.SR WARD S R CONSULTANT