55Y/F With Seizures
2023 DEC
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Patient and his/her attenders have been informed and their consent has been taken.
55Y/ F Came with involuntary movements of both upper and lower limb since 30 minutes.
HOPI
Patient was apparently asymptomatic 30 minutes back then developed involuntary movements of both upper and lower limbs, sudden in onset, continuous. Associated with upward rolling of eyeballs, involuntary micturition, froth from mouth, 1episode of fever.
Associated with deviation of angle of mouth towards left with tongue bite.
No history of involuntary defecation.
No history of head injury, vomiting, loose stools.
PAST HISTORY
Known case of epilepsy since 20 years and on medication Tab. Phenytoin 100mg PO OD.
During Last Pregnancy approx 24 years back she had ?Pre-eclampsia
Not a known case of Diabetes, hypertension, asthma, CAD, CVA.
FAMILY HISTORY
Not significant
PERSONAL HISTORY
Diet - Mixed
Appetite - Normal
Sleep - Disturbed
Bowel and bladder movements -regular
No known allergies
No addictions
GENERAL EXAMINATION
Patient is conscious, uncooperative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.
Vitals-
Temp: 102.1°F
PR- 128bpm
RR- 28cpm
BP- 140/80 mmHg
Spo2 -94%at RA
Grbs- 222mg/dl
SYSTEMIC EXAMINATION
CVS- S1 S2 heard, no murmurs, no thrills
RS - NVBS heard
P/A - Soft, non tender
CNS- E1V1M6
Speech no response
Cranial nerves cannot be elicited
Sensory system cannot be elicited
Tone of both upper and lower limbs- normal
Power cannot be elicited
REFLEXES-
B. T. S. K. A
R. 2+ 2+ - 2+ -
L. 2+ 2+ - 2+ -
INVESTIGATIONS
Hb- 13.1. Tlc- 11.900. Plt- 1.66
LFT:
TB- 0.83 DB- 0.17. AST/ALT - 18/10
ALP-122. TP- 7.4. Alb- 3.73
RFT
U-26. S.Cr- 0.7 Na+146 K+ 4.2 Cl- 98
Troponin I 20.3 pg/ml.
Ecg
Chest X Ray
DIAGNOSIS
GENERALISED TONIC CLONIC SEIZURES 2° CVA
TREATMENT
IV Fluids 75ml/hour
Inj Lorazepam 2ml IV STAT
Inj Levitracetam 2gm IV STAY F/B 1gm IV BD
Inj Ceftriaxone 20ml IV BD
Inj Optinueron 1ampole in 100ml NS IV OD
Tab Atorvastatin PO OD
Tab Ecospirin 75 mg PO OD
SOAP DAY 2
S: No episode of seizure.
Fever subsided
O : Patient is conscious, coherent, cooperative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.
Vitals-
Temp: 97.8°F
PR- 85bpm
RR- 20cpm
BP- 120/80 mmHg
Spo2 -98%at RA
Grbs- 134mg/dl
CVS- S1 S2 heard, no murmurs, no thrills
RS - NVBS heard
P/A - Soft, non tender
CNS- E4V4M5
Speech normal
Tone of both upper and lower limbs- normal
Power cannot be elicited
REFLEXES- B. T. S. K. A P
R. 2+ 2+ - 2+ - Extensor
L. 2+ 2+ - 2+ - Extensor
A: GENERALISED TONIC CLONIC SEIZURES 2° CVA
P : IV Fluids 75ml/hour
Inj Levicetram 14ml IV BD
Inj Ceftriaxone 20ml IV BD
Inj Optinueron 1ampole in 100ml NS IV OD
Tab Atorvastatin PO OD
Tab Ecospirin 75 mg PO OD
Inj Lorazepam 2ml IV SOS
SOAP DAY 3
S: Post ictal confusion present.
No episode of seizure.
No Fever spikes.
O : Patient is conscious, coherent, cooperative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.
Vitals-
Temp: 97.8°F
PR- 78bpm
RR- 18cpm
BP- 110/70 mmHg
Spo2 -98%at RA
Grbs- 134mg/dl
CVS- S1 S2 heard, no murmurs, no thrills
RS - NVBS heard
P/A - Soft, non tender
CNS- E4V4M5
Speech normal
Tone of both upper and lower limbs- normal
Power of both upper and lower limbs- 5/5
REFLEXES- B. T. S. K. A P
R. 2+ 2+ - 2+ - Flexion
L 2+ 2+ - 2+ - Flexion
A: GENERALISED TONIC CLONIC SEIZURES 2° CVA
P : IV Fluids 75ml/hour
Inj Levicetram 500mg IV BD
Inj Ceftriaxone 2gm IV BD
Inj Optinueron 1ampole in 100ml NS IV OD
Tab Atorvastatin 20mg PO OD
Tab Ecospirin 75 mg PO OD
Inj Lorazepam 2ml IV SOS
SOAP DAY 3
S:No episode of seizure.
No Fever spikes.
O : Patient is conscious, coherent, cooperative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.
Vitals-
Temp: 97.8°F
PR- 72bpm
RR- 18cpm
BP- 110/80 mmHg
Spo2 -98%at RA
Grbs- 122mg/dl
CVS- S1 S2 heard, no murmurs, no thrills
RS - NVBS heard
P/A - Soft, non tender
CNS- E4V4M5
Speech normal
Tone of both upper and lower limbs- normal
Power of both upper and lower limbs- 5/5
REFLEXES- B. T. S. K. A P
R. 2+ 2+ - 2+ - Flexion
L 2+ 2+ - 2+ - Flexion
A: GENERALISED TONIC CLONIC SEIZURES 2° CVA
P : IV Fluids 75ml/hour
Tab Levicetram 500mg PO BD
Inj Ceftriaxone 2gm IV BD
Inj Optinueron 1ampole in 100ml NS IV OD
Tab Atorvastatin 20mg PO OD
Tab Ecospirin 75 mg PO OD
Inj Lorazepam 2ml IV SOS
DISCUSSION : GTCS
STATUS EPILEPTICUS
Comments
Post a Comment