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Sasira Kasinadhuni
ROLL NO 166
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 eeduluru (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 on 27th November, 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 27/11/21 :
Examination videos:
Investigations :
On 27/11/21-
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
I would like to thank Dr.Chandana ma’am (PG) and Dr. Pavani ma’am (intern) for this opportunity to blog this case.
