55 year old presenting with seizures

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Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

I've 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.

55 year old male hailing from  nalgonda driver by occupation was bought to the casualty with complaints of 2 episodes of seizures 

> Patient was apparently asymptommatic 6 months ago, then had a history of seizure and deviation of mouth to the right, following which he was taken to near by hospital where patient was diagnosed to be hypertensive for which anti hypertensives were prescribed and he was discharged after 8 days.

> Patient’s attender’s have taken him to Hyderabad for further treatment but bought him to our hospital the very next day , where the patient was admitted for 7 days , advised physiotherapy and was prescribed medicines .

 

>2 days later patient presented to hospital with haematuria , for which he was treated and discharged.

> 2 months ago , there’s history of oral hypoglycemic agents intake without food intake , after which patient developed altered sensorium for which he was admitted in our hospital and was diagnosed with medication induced hypoglycemia for which he was treated and discharged.

> At around 7: 30 am today, while patient's attender  was giving a bath to the patient, he had tonic posturing of right upper limb with uprolling of eyeballs, frothing+ and patient became alright after 10 minutes

> At around 1pm patient had similar episode when he was sleeping on bed and was immediately brought here 

 

> No history of fever, vomitings, headache

Past history :

Patient is a known hypertensive on TAB. TELMA 40 MG OD

Known diabetic on TAB. METFORMIN 500 MG BD

History of CVA on TAB. ECOSPIRIN 

Patient has a lesion over his right buttock since 1yr uses an (?)ointment  local application.

Personal history : 

Patient takes mixed diet, appetite normal, sleep adequate, bowel and bladder habits regular 

Examination :

Vitals at the time of admission:

Temp: afebrile

PR: 110 bpm

BP: 160/100 mm hg

RR: 18cpm

Spo2: 98% at room air

GRBS: 107 mg/ dl 

CVS: S1S2+

RS: BEA+, NVBS+

P/ A: SOFT, NON TENDER

CNS:

Deviation of mouth to right

Speech- irrelavant

Cranial nerves-

Motor system 

Power

                UL                  LL

    Right.   5/5                5/5

    Left.      0/5.               0/5

Tone- B/L UL- increased

Reflexes B T. S K A plantar- 

             L 3+ 3+ 3+ +3 -. flexed 

            R - 1+ 3 +2 +2. - extensor

Gait- could not examine 

D- seizures under evaluation with post ictal confusion with left hemiplegia

With diabetes and hypertension 

Treatment:

INJ. LEVIPIL 1GM IV STAT 

INJ LEVIPIL 500 MG IV BD

INJ LORAZ 2CC IF SEIZURES+

TAB. TELMA 40 MG PO OD

INJ HAI ACC TO GRBS

RT FEEDS MILK WITH PROTEIN POWDER TID

BP/ PR CHARTING 2ND HOURLY

GRBS MONITORING 6TH HOURLY

W/F SEIZURE ACTIVITY

On day of admission

Day 2

Examination videos:

          

                                        

 Investigations :       

Haemogram :-

Hb - 11.0 gm/dl 

TC - 6,200 cells /cu mm

Neutrophils - 70%

Lymphocytes - 25%

Eosinophils - 01%

Monocytes- 0.3%

PCV - 32.9

MCV- 73.8

MCH -24.7

MCHC - 33.4

RDW -CW - 13.7

RDW-SD - 36.6

RBC count - 4.46

PLT - 2.77 lakh/ cu mm

Normocytic normochromic

No hemoparasites

RBS - 99 mg/dl

Blood urea - 36 mg/dl

LFT :-

TB - 0.77mg/dl

DB -  0.2 mg/dl

AST - 10 IU/L

ALT - 09 IU/L

ALP - 242 IU/L

TP - 7.7 gm/dl

ALB - 3.5 gm/dl

A/G - 0.87

Serum Ca - 10.2mg/dl

Serum Creatinine - 1.4 mg/dl

Serum Na+ - 143 meq/L

Serum K+ - 3.2 meq/L

Serum Cl - 106 meq/L

Serum Mg - 2.0 mg/dl

Troponin I - negative

ABG:-

pH - 7.44

pCO2 - 32.9

pO2 - 32.9

HCO3 - 22

O2 sat - 95%

O2 count - 15.5

HbsAg - negative

HIV - non reactive 

HCV - non reactive

Imaging :

Provisional diagnosis: CVA with left sided hemiplegia

Soap notes 

No seizure episodes

Lethargic No fever spikes

0

Drowsy but arousable

BP:120/90 mmHg

PR:112 bpm

TEMP:98° f 

CVS:S1 S2 HEARD 

CNS: deviation of mouth to right

GRBS:106 mg/dl 

RS:BAE + ,NVBS

Tone: R.     L

UL      N   Increased

LL      N Increased

Power:

        R     L

UL  5/5  0/5

LL 5/5 0/5

Reflexes:BTSKA P

Right.      1+ 1+ 1+ 3+ 1+ flex

 Left        3+3+ 2+ 3+ 1+ ext

A

SEIZURES UNDER EVALUATION WITH POST ICTAL CONFUSION

DM +

HTN +

H/O CVA left sided

P

INJ.Levipil 500 mg iv bd

Inj.Loraz 2 cc iv sos

Inj Pantop 40 mg iv od

GRBS 6th hrly (8am 2pm 8pm 2am)

Inj H Actrapid acc to GRBS

Watch for seizure activity 

RT feeds milk 200ml RT TID

free water 100 ml 2nd hrly 

BP/ PR charting 2nd hrly

55 year old with abdominal pain and breathing difficulty

 

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

Chief complaints : 

Abdominal pain since 5 days 

Breathing difficulty since  2 days 

History of present illness: 

Patient was apparently asymptomatic 5 days back then he developed abdominal pain after taking alcohol continuously for 3 days . It is sudden in onset and gradually progressive and dragging type which is aggravated on alcohol intake and relieved on medication. Previously visited other hospitals , after onset of abdominal pain but it didn't relieve inspite of medication .

There is h/o altered sensorium since 3 days . He is unable to identify his wife and pulling away the cannulas.

There is history of nausea where he vomited by inducing with his hand . 

There is history of weight loss also since 1 year. 

History of sob which is grade 4 

History of fever yesterday.

Past history: 

A known case of diabetes since 2 years on medication .

History of TB diagnosed 2 months back on regular medication.

Not a known case hypertension,asthma,epilepsy,CVD.

Personal history: 

Bowel and bladder - regular and there is increased frequency of urine seen when sugar levels are increased .

Not sleeping adequately since 2 days 

Alcohol consumption since 30 yrs occasionally for festivals but he drinks  continuously for 3 days of 1 full bottle quantity.

History of tobacco smoking since 25 yrs.

Family history: 

Not significant

General examination:

Patient is conscious ,not co operative ,not oriented to time place person 

Not well built and nourished .

Afebrile

GCS : 

          EYE OPENING :4 (opened spontaneously)

          VERBAL RESPONSE: 3

           MOTOR RESPONSE :3 

                        Total :10

        Pallor : present

        Icterus : absent

        Cyanosis : absent

        Clubbing : absent 

        Lymphadenopathy : absent 

Vitals:-

Pulse - 90bpm 

RR - 22 cpm

Bp- 140 / 70 mm hg 

Temperature- 97.4°c 

Spo2- 99%at RA.

GRBS

5:30-600

7:30- 390

8:30-380

9:30- 383

10:30- 382

11:30- 260

12:30- 210

1:30- 220

2:30- 206

3:30- 207

4:30- 147

5:30- 77

6:30- 121

7:30- 131

Systemic examination:-

Examination of oral  cavity- 

No dental caries, no gum hypertrophy , oral hygiene is maintained , no postnasal drip 

Abdominal examination- 

INSPECTION:

Shape – scaphoid, flat,not distended

Flanks – free 

Umbilicus – Position- central, Shape-inverted

Skin –  No scars, no sinuses,no striae, no nodules,no  scratch marks,

Dilated veins – not present 

All quadrants  are equally Movable with respiration  ,no visible gastric peristalsis.

No abdominal distension .

PALPATION:

No local raise of temperature.

Superficial Palpation – Tenderness not elicited.

Deep Palpation-

Liver-

Not palpable

Spleen-

Not palpable

Kidney-

Bimanually Not palpable

PERCUSSION:

Fluid Thrill/Shifting dullness/Puddle’s sign - not elicited

Liver span - 6cm 

AUSCULTATION:

Bowel sounds are heard.

EXAMINATION OF OTHER SYSTEMS

CARDIOVASCULAR SYSTEM:

S1, S2 are heard.

EXAMINATION OF RESPIRATORY SYSTEM:

Normal vesicular breath sounds heard.

EXAMINATION OF NERVOUS SYSTEM:

Altered sensorium, irrelevant talking and unable to recognise his wife and He is pulling away the cannula.

INVESTIGATIONS:-

Usg report-

On 3rd day : 

Patient reviewed 

Pain decreased yesterday denies for alcohol cravings.

On examination- patient drowsy

Bp - 110/70 mmHg 

PR-102 / min

SpO2 - 98% on room air 

 

Lab investigations- 

ABG analysis: 

pH -7.44

PCo2 - 25.3 

HCO3 - 17.1 

 

Serum urea - 47 

Serum creatinine- 0.8 

Na+ - 133 

K+ - 3.2 

Cl-  - 94

Treatment:-

1. IVF- NS- 1L for 3hrs.

2. Inj HAI 6IU IV/STAT.

3. GRBS monitoring hrly.

4.IVF-5% Dextrose if GRBS<250mg/dl.

5.Inj THIAMINE 100mg in 100 ml NS/IV/BD.

6.Inj OPTINEURON 1 amp in 100ml NS/IV/OD.

PROVISIONAL DIAGNOSIS:-

Diabetic ketoacidosis with known case of diabetes milletus.

50 year old with SOB since 10 days

  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

50 years Years old male came to OPD with cheif complaints of shortness of breath since 10 days.

Complaints of decreased urine output,nausea,B/L pedal edema and  constipation since 10 days.

Patient was aparently asymptomatic 15 years back, then developed B/L pedal edema , shortness of breath and was brought to our hospital 1 session of HD done.Patient was diagnosed with CKD 15 years back and was treated conservatively(on and off).

Now again 10 days back he came to OPD.

Past History :-

K/C/O HTN since 10 months and on regular medications.

Not a known case of DM , asthama , TB , Thyroid , epilepsy.

Personal History :-

Diet : mixed

Apetite : decreased since 10 days.

Sleep : adequate.

Bowel movements : irregular

Decreased urine output.

No any addictions.

On examination, patient is C/C/C .

Pallor present.

B/L pitting edema present till knees.

No cyanosis , icterus, clubbing , lymphadenopathy.

Temperature - 98.5*F

PR - 112/ min

RR - 18cpm

BP - 110/90 mmhg

Spo2 - 99% at RA

Grbs - 115 mg%

CVS :- S1 , S2 heard

RS - BAE present

P/A - soft and non tender

CNS - No focal Neurological deficet.

RFT :-

Serum Albumin :-

USG :-

Serology:-

Serology :-

Serology:-

CBP:-

CUE:-

Provisional diagnosis :-

Chronic kidney disease with Polycystic kidney disease and K/C/O HTN since 10 months.

Updates 

Day 2 :

Urea :- 219 mg/dl

Creatinine : 17.5 mg/dl

Hb : 5.2 gm%

 

1 session of HD was performed on 18th along with transfusion of 1 unit of PRBC.

S :-

B/L Pedal edema present.

Decreased urine output.

Nausea present.

O :-

BP - 160/80 mmhg

PR - 81 bpm

Temp - afebrile

RR -16cpm

Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day

2) Salt restriction less than 2.4 gm/day

3) TAB. LASIX 40MG PO/TID

4) TAB. NICARDIA 20 MG PO/BD

5) TAB OROFER-XT PO/OD

6) TAB NODOSIS 550MG PO/BD

7) TAB SHECAL 500MG PO/OD

8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE

9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS

10) TAB ARKAMINE 0.1MG PO/OD

11) TAB ZOFER 4MG PO/TID

day 3:

Urea : 109 mg/dl

Creatinine : 11.3 mg/dl

Hb : 7.4 gm%

S :-

B/L Pedal edema present.

Decreased urine output.

Nausea present.

O :-

BP - 160/80 mmhg

PR - 81 bpm

Temp - afebrile

RR -16cpm

Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day

2) Salt restriction less than 2.4 gm/day

3) TAB. LASIX 40MG PO/TID

4) TAB. NICARDIA 20 MG PO/BD

5) TAB OROFER-XT PO/OD

6) TAB NODOSIS 550MG PO/BD

7) TAB SHECAL 500MG PO/OD

8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE

9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS

10) TAB ARKAMINE 0.1MG PO/OD

11) TAB ZOFER 4MG PO/TID

Day 4:

Urea : 115 mg/dl

Creatinine : 11.2 mg/dl

Hb : 6.8 gm%

1 session of HD was done along with transfusion of 1 unit of PRBC.

S :-

B/L Pedal edema present.

Decreased urine output.

Nausea present.

O :-

BP - 160/80 mmhg

PR - 81 bpm

Temp - afebrile

RR -16cpm

Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day

2) Salt restriction less than 2.4 gm/day

3) TAB. LASIX 40MG PO/TID

4) TAB. NICARDIA 20 MG PO/BD

5) TAB OROFER-XT PO/OD

6) TAB NODOSIS 550MG PO/BD

7) TAB SHECAL 500MG PO/OD

8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE

9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS

10) TAB ARKAMINE 0.1MG PO/OD

11) TAB ZOFER 4MG PO/TID

Day 5 

Urea : 42 mg/dl

Creatinine : 4.9 mg/dl

Hb : 8.4 gm%

1 session of HD was done.

S :-

B/L Pedal edema present.

Decreased urine output.

O :-

BP - 150/80 mmhg

PR - 83 bpm

Temp - afebrile

RR -17cpm

Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day

2) Salt restriction less than 2.4 gm/day

3) TAB. LASIX 40MG PO/TID

4) TAB. NICARDIA 20 MG PO/BD

5) TAB OROFER-XT PO/OD

6) TAB NODOSIS 550MG PO/BD

7) TAB SHECAL 500MG PO/OD

8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE

9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS

10) TAB ARKAMINE 0.1MG PO/OD

11) TAB ZOFER 4MG PO/TID

Day 6 

Urea : 36 mg/dl

Creatinine : 2.9 mg/dl

Hb : 9.1 gm%

1 session of HD was done along with transfusion of 1 unit of PRBC.

S :-

B/L Pedal edema present.

Decreased urine output.

Nausea present.

O :-

BP - 130/80/90 mmhg

PR - 82 bpm

Temp - afebrile

RR -16cpm

Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day

2) Salt restriction less than 2.4 gm/day

3) TAB. LASIX 40MG PO/TID

4) TAB. NICARDIA 20 MG PO/BD

5) TAB OROFER-XT PO/OD

6) TAB NODOSIS 550MG PO/BD

7) TAB SHECAL 500MG PO/OD

8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE

9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS

10) TAB ARKAMINE 0.1MG PO/OD

11) TAB ZOFER 4MG PO/TID

Day 7 

Hb : 9.8%

S :-

B/L Pedal edema present.

Decreased urine output.

O :-

BP - 130/80 mmhg

PR - 81 bpm

Temp - afebrile

RR -17cpm

Spo2 - 99% at RA

P :-

1) Fluid restriction less than 1L / day

2) Salt restriction less than 2.4 gm/day

3) TAB. LASIX 40MG PO/TID

4) TAB. NICARDIA 20 MG PO/BD

5) TAB OROFER-XT PO/OD

6) TAB NODOSIS 550MG PO/BD

7) TAB SHECAL 500MG PO/OD

8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE

9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS