GM CASES

Date of admission: 10-08-2021

63 year old male presented to the casualty with history of one episode of involuntary movements of both upper and lower limbs around 11:00 pm, lasting for 5-10 min associated with ictal cry, uprolling of eyeballs and deviation of mouth with ?cheek bite followed by post ictal confusion lasting for 10-15 min.
No H/o involuntary micturition or defecation.
He was taken to a local hospital, where he was administered epitoun and was referred to KIMS (around 1am)
After presentation there was another episode of involuntary movements of both upper and lower limbs, GTCS type with deviation of mouth, lasting for 1-2 mins followed by post ictal confusion for 2-3 min.

He is a known case of seizures since 30 years and on medication carbamazepine 200mg OD & 400mg HS. But he didn't take medication since 2 days.
H/o seizures yearly once or twice for 10 years and was seizure free for the past 10 years.

Known case of type 2 DM since 6 months and on GLIMI 1mg, METFORMIN 500mg

Known case of ?asthma (occasional use of MDI, salbutamol)

Personal history:
Diet - veg
Appetite - normal
Sleep - adequate
Bowel and bladder habits - regular
No addictions

Family history:
No significant history

General examination:
On presentation to us, he was conscious, coherent, co-operative
Moderately built and nourished
No signs of pallor, icterus, cyanosis, clubbing, koilonychia, generalized lymphadenopathy
Vitals at the time of admission:
Temp - 98.4 F
PR - 110 BPM
Bp - 130/80 mm Hg
RR - 18cpm
Spo2 - 98% at room air
GRBS - 166mg/dl

Systemic examination:
CNS:
Speech - normal
No signs of meningeal irritation
Motor & sensory system - normal
Reflexes - normal
Cranial nerves - intact

CVS :
S1, S2 heard
No thrills, Murmurs

Respiratory system:
Position of Trachea - central
NVBS heard
No added sounds

Per abdomen:
Soft, non tender
No palpable masses
Hernial orifices - normal
Bowel sounds heard

Provisional Diagnosis:
Seizures secondary to non compliance to Antiepileptic drugs

Investigations:
RBS, RFT, LFT, Hemogram:
ECG:
Treatment given:
1. IVF - 1 NS @ 75ml/hr with 1 ampoule of OPTINEURON
2. Inj. LEVIPIL 1gm IV stat
3. Inj. ZOFER 4 mg IV SOS
4. Inj. PAN 40mg IV OD
5. Tab. CARBAMAZEPINE 200mg/PO @ 8:00 am
6. Tab. CARBAMAZEPINE 400mg/PO/HS
7. Tab. GLIMI-M1/PO/OD
8. BP/PR/SPO2 charting 4th hourly
9. GRBS Charting 6th hourly

Discharge summary:
Date: 10-08-21, 3:30 pm
Ward: ICU
Unit: 1

Treating Faculty:
Dr. Pallavi (Internee)
Dr. Avani (Internee)
Dr. Akshitha (Internee)
Dr. Sree Valli (Internee)
Dr. Roshna (Internee)
Dr. Tejaswini (Internee)
Dr. Vijay Dhanush (Internee)
Dr. Vinay (PGY1)
Dr. Shashikala (PGY1)
Dr. Aashitha (PGY2)
Dr. Usha sree (PGY2)
Dr. K. Vaishnavi (PGY2)
Dr. Arjun (ASST PROF)
Dr. Rakesh Biswas (HOD & PROF)

Diagnosis:
Seizures secondary to non compliance to Antiepileptic drugs

Case history:
63 year old male presented to the casualty with history of one episode of involuntary movements of both upper and lower limbs around 11:00 pm, lasting for 5-10 min associated with ictal cry, uprolling of eyeballs and deviation of mouth with ?cheek bite followed by post ictal confusion lasting for 10-15 min.
No H/o involuntary micturition or defecation.
He was taken to a local hospital, where he was administered epitoun and was referred to KIMS (around 1am)
After presentation there was another episode of involuntary movements of both upper and lower limbs, GTCS type with deviation of mouth, lasting for 1-2 mins followed by post ictal confusion for 2-3 min.

He is a known case of seizures since 30 years and on medication carbamazepine 200mg OD & 400mg HS. But he didn't take medication since 2 days.
H/o seizures yearly once or twice for 10 years and was seizure free for the past 10 years.

Known case of type 2 DM since 6 months and on GLIMI 1mg, METFORMIN 500mg

Known case of ?asthma (occasional use of MDI, salbutamol)

Personal history:
Diet - veg
Appetite - normal
Sleep - adequate
Bowel and bladder habits - regular
No addictions

Family history:
No significant history

General examination:
On presentation to us, he was conscious, coherent, co-operative
Moderately built and nourished
No signs of pallor, icterus, cyanosis, clubbing, koilonychia, generalized lymphadenopathy
Vitals at the time of admission:
Temp - 98.4 F
PR - 110 BPM
Bp - 130/80 mm Hg
RR - 18cpm
Spo2 - 98% at room air
GRBS - 166mg/dl

Systemic examination:
CNS:
Speech - normal
No signs of meningeal irritation
Motor & sensory system - normal
Reflexes - normal
Cranial nerves - intact

CVS :
S1, S2 heard
No thrills, Murmurs

Respiratory system:
Position of Trachea - central
NVBS heard
No added sounds

Per abdomen:
Soft, non tender
No palpable masses
Hernial orifices - normal
Bowel sounds heard

Investigations:
MRI Brain:
Few acute lacunar infarcts in bilateral cerebral hemispheres.
Bilateral thin subdural collections over the fronto-parietal convexities.

Treatment given:
1. IVF - 1 NS @ 75ml/hr with 1 ampoule of OPTINEURON
2. Inj. LEVIPIL 1gm IV stat
3. Inj. ZOFER 4 mg IV SOS
4. Inj. PAN 40mg IV OD
5. Tab. CARBAMAZEPINE 200mg/PO @ 8:00 am
6. Tab. CARBAMAZEPINE 400mg/PO/HS
7. Tab. GLIMI-M1/PO/OD
8. BP/PR/SPO2 charting 4th hourly
9. GRBS Charting 6th hourly

Advice at discharge:
1. Tab. CARBAMAZEPINE 200mg/PO/OD
2. Tab. CARBAMAZEPINE 400mg/PO/HS
3. Tab. PAN 40 mg PO/OD
4. Tab. ZOFER 4mg/PO/SOS
5. Tab. GLIMI M1 PO/OD

Comments

Post a Comment

Popular posts from this blog

GM CASES

Image
Date of Admission: 28-06-2021 A 52-year-old man presented to the OPD with Cheif Complaints of abdominal distension from the past 7 days. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 2 years back, then he had a non healing injury to the right foot which raised a suspicion of Diabetes mellitus. Then they went to neatest medical care and diagnosed with Diabetes mellitus type 2 and was started on Tab. GLIMI M2 OD.  2 years back he complained of Tingling in the upper limbs up to the palms, in the lower limbs up to the knee.   15 Days back patient presented to the casualty with Abdominal Distension NOT associated with pain, No nausea, No Vomiting, No loose stools and was diagnosed with  Alcoholic Liver Disease, AKI secondary to UTI on CKD, secondary to ? Diabetic nephropathy, Hepatic encephalopathy grade 2 From the past 7 Days, He Complains of Abdominal Distension. From the past 5 days, he complains of Constipation and has not passed stools since 5 days. He also complain
Read more

42 Year old woman with multiple health events since birth

Image
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 a diagnosis and treatment plan.  You can find the entire real patient clinical problem in this link here..https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1 Following is my analysis of this patient's problem: The problems in order of priority I found are  1) Headache 2) Swelling 3) Sleep disturbances 4) Mood disorders 1.Headache: -present since age 2 years -became worse with menarche and with the usage of nuvaring -associated with visual aura before the attack(scotomas, flashes of light,seeing rainbow colors) -associated with giddiness, weakness/numbness of left half of the body So,the cause for headche could be HEMIPLEGIC MIGRAINE. Differential diagnosis:      Stroke, Brain tumors   
Read more

GM CASES

Image
50 year old female came with complaints of abdominal distension, shortness of breath, burning micturition, decreased appetite, nausea since 5 days and dry cough since yesterday. History of present illness: Patient was apparently asymptomatic 2 years back, then diagnosed with pancreatitis and AKI, for which she underwent 2 sessions of hemodialysis. At that time, she also tested positive for dengue. 2 months back, she tested positive for covid 19 and received medication at home. She was also diagnosed to be diabetic and hypertensive, but on irregular medication. Now, she c/o abdominal distension, decreased appetite, nausea, burning micturition and sob on exertion (grade 2); for which she went to local hospital but her symptoms did not subside. So, she came here for better treatment. No h/o palpitations, chest pain, fever, decreased urine output, pedal edema, orthopnea, PND, vomitings. Past history: Not a known case of asthma, TB, epilepsy, CAD, CVA, thyroid disorders. No h/o surgeries an
Read more