Monday 7 March 2022

Curious case of 55 year old male with seizures



 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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."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

     

55 year old male hailing from nalgonda , farmer by occupation presented to our casuality in post cardiac arrest- intubated state on 5th march at 4:27pm

HOPI




▪︎No loss of consciousness,seizures,giddiness following trauma


●Not a known case of HTN,DM,ASTHMA,STROKE


PERSONAL HISTORY

●Non vegetarian consumes pork meat with normal appetite,regular B&B movements

● No known allergies ,smoker and alcholic for the past 20 years and no history of weight loss

Family history

● h/o seizures in both of his grand children 

examination

• Vitals at the time of admission:
Temp: 99.8•F
PR: 114bpm
RR:18cpm
BP: 110/60mm hg
Spo2: 96%on O2 
GRBS: 196mg/dl 

CVS: S1S2+
RS: BEA+, NVBS+
P/ A: SOFT, NON TENDER
CNS: 
Pupils - b/l nsrl
Reflexes   B   T   S. A. K.  plantar- 
            L - 2+ 2+ 2+ -  3+  extended
           R - 2+ 2+ 2+ -  +3  extended



■ Provisional diagnosis - seizures under evaluation(? Alcohol withdrawal seizures) with post ictal confusion 
     ? Hypoxic encephalopathy 
     Post CPR status day 5

Rx 

1. Head end elevate 30•

2. Inj . MEROPENEM 1gm/IV/BD

3. Inj.LEVIPIL 500mg / IV/ BD

4.Inj. Mannitol 100ml/IV/BD

5.Inj. MIDAZO LAM 10mg - 50 mgNS (@ 3ml / hr)

6.Inj. Pantop 40mg/IV/OD

7. Inj.Neomol 100 ml/if temp >101.5•

8.RT feeds —-100 ml with nills

(2 hourly )        100ml with free water

9. Vitals monitoring hrly

10.Fever chart Hourly

11.Inj.thiamine 2AMP in 100 ml ns/iv/bd 


● Ecg taken on day 1

■ Investigations done - 









Updates 


■ Day 2 Soap notes - O/E  patient is on mechanical ventilator 
Gcs- E1 V M2
Febrile -100.1•F
BP-140/80mmHg
PR-112bpm regular , normal volume
RR-18cpm
Cvs: S1S2 heard no murmurs
RS:  NVBS+
P/ A: SOFT, NON TENDER
CNS: pupils -b/l nsrl (at 7:00AM)
            
Reflexes   B   T   S. A. K.  plantar- 
            L - 2+ 2+ 2+ -  3+  extended
           R - 2+ 2+ 2+ -  +3  extended

 (at 10:35AM) Sluggish pupil reaction
                         Dolls eye absent


Rx 

1. Head end elevate 30•

2. Inj . MEROPENEM 1gm/IV/BD

3. Inj.LEVIPIL 500mg / IV/ BD

4.Inj. Mannitol 100ml/IV/BD

5.Inj. Pantop 40mg/IV/OD

6. Inj.Neomol 100 ml/if temp >101.5•

7.RT feeds —-100 ml with nills

(2 hourly )        100ml with free water

8. Vitals monitoring hrly

9.Fever chart Hourly

10.inj Monocef 1gm/iv/bd

11.Inj.thiamine 2AMP in 100 ml ns/iv/bd 


Investigations-






● Diagnosis - seizures 2• to ? tuberculoma/NCC

                                              ? Alcohol

         With hypoxic encephalopathy, post cpr status day 6,  mechanical ventilation day 5


■ Day 3 soap notes 

O/E  patient is on mechanical ventilator 

Gcs- E1 V M2

Fever spikes+

BP-130/90mmHg
PR-120bpm regular , normal volume
RR-18cpm
Cvs: S1S2 heard,muffled heart sounds
RS:  NVBS+
P/ A: SOFT, NON TENDER
CNS: pupils -b/l nsrl
            
Reflexes   B   T   S.   A.  K.    plantar- 
            L - 2+ 2+ 2+    -   -      extended
           R - 2+ 2+ 2+    -    -      extended
Spo2-92%


Rx 

1. Head end elevate 30•

2. Inj .MIDAZOLAM 10mg in 50ml ns @3ml/hr

3. Inj.LEVIPIL 500mg / IV/ BD

4.Inj. Mannitol 100ml/IV/BD

5.Inj. Pantop 40mg/IV/OD

6. Inj.Neomol 100 ml/if temp >101.5•

7.RT feeds —-100 ml with nills

(2 hourly )        100ml with free water

8. Vitals monitoring hrly

9.Fever chart Hourly

10.inj Monocef 1gm/iv/bd

11.Inj.thiamine 2AMP in 100 ml ns/iv/bd 

Advised 2D echo


Investigations-   






● Diagnosis - seizures 2• to ? tuberculoma/NCC

                                              ? Alcohol

         With hypoxic encephalopathy, post cpr status day 7,  mechanical ventilation day 6

Fever chart




S:- no fever spikes
O- O/E : patient is on mechanical ventilator
          PEEP- 5
          FiO2 - 40% 
          VT - 400ml
          Timp : 2.1
          VITALS:
temp- afebrile
BP: 110/90mm hg 
PR: 115 bpm. 
RR: 16 cpm 
spo2: 99% with Fio2 40%
GRBS: 168 mg/dl
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender 
CNS: Pupils :B/L NSRL 
GCS: E1VTM2
Cough reflex present
corneal reflex present
conjunctival reflex present
REFLEXES : right. left 
       Biceps   2+                   -
       Triceps . 2+                  2+
    Supinator  2+                 2+
       Knee        3+              3+ 
      Ankle      -                  -
      Plantar    mute    mute
A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 8 , mechanical ventilator day 7
P: ENT opinion i/v/o tracheostomy




Day 4:(9/3/22) soap notes


S:- fever spikes present

O- O/E : patient is on mechanical ventilator
          PEEP- 5
          FiO2 - 40% 
          VT - 400ml
          Timp : 2.1
          VITALS:
temp- 100.9 F
BP: 120/90mm hg @ NORAD 6ml /hr
PR: 114 bpm. 
RR: 16 cpm 
spo2: 99% with Fio2 40%
GRBS: 129 mg/dl
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender 
CNS: Pupils :B/L NSRL 
GCS: E1VTM1
Cough reflex present
corneal reflex present
conjunctival reflex present
REFLEXES :       right                  left 
       Biceps             2+                     2+
       Triceps            2+                     2+
    Supinator           2+                     2+
       Knee               3+                     3+ 
      Ankle                -                        -
      Plantar             extensor            extensor

A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 9 , mechanical ventilator day 8



Day 5(10/3/22) soap notes:


S:- no fever spikes 

O- O/E : patient is on mechanical ventilator
          PEEP- 7
          FiO2 - 40% 
          VT - 400ml
          Timp : 2.6
          VITALS:
temp- Afebrile
BP: 90/50mm hg @ NORAD 8ml /hr
PR: 109 bpm. 
RR: 14 cpm 
spo2: 99% with Fio2 40%
GRBS: 181 mg/dl
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils :B/L NSRL 
GCS: E1VTM1
Cough reflex present
corneal reflex present
conjunctival reflex present
REFLEXES : right. left 
       Biceps   2+                   2+
       Triceps . 2+                  2+
    Supinator  2+                 2+
       Knee        2+              2+ 
      Ankle      -                  -
      Plantar    extensor    extensor

A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 10, mechanical ventilator day 9

Day 6 (11/3/22) soap notes


S:- no fever spikes 

O- O/E : patient is on mechanical ventilator
          PEEP- 7
          FiO2 - 40% 
          VT - 400ml
          Timp : 1.9
          VITALS:
temp- Afebrile
BP: 140/80mm hg @ NORAD 10ml /hr,vaso 2ml/hr
PR: 73 bpm. 
RR: 14 cpm 
spo2: 99% with Fio2 40%
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils :B/L sluggish reaction to light
GCS: E1VTM1
corneal reflex present
conjunctival reflex present
REFLEXES : right. left 
       Biceps   2+                   2+
       Triceps . 2+                  2+
    Supinator  2+                 2+
       Knee        2+              2+ 
      Ankle      -                  -
      Plantar    extensor    extensor

A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 11, mechanical ventilator day 10
P: MRI

Day 7 (12/3/22) soap notes

ICU bed 6
Day 7
http://tejaswini166.blogspot.com/2022/03/cbble-udhc-similar-cases.html
S:- no fever spikes 
O- O/E : patient is on mechanical ventilator
          PEEP- 6
          FiO2 - 30% 
          VT - 460ml
          Timp : 1.9
          VITALS:
temp- Afebrile
BP: 150/70mm hg 
PR: 79 bpm. 
RR: 17cpm 
GRBS: 149mg/dl
spo2: 99% with Fio2 30%
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils : NSRL
GCS: E2VTM2
cough reflex: present
corneal reflex :negative
conjunctival reflex: present
doll's eye: negative
REFLEXES : right. left 
       Biceps   3+                   3+
       Triceps . 3+                  3+
    Supinator  3+                 3+
       Knee        3+              3+ 
      Ankle      3+                 3+
      Plantar    extensor    extensor

A: Seizures secondary to ? tuberculoma/?NCC with chronic hypoxic encephalopathy with post CPR status day 12, mechanical ventilator day 11
P : EEG

Day 8 (13/3/22) soap notes


S:- no fever spikes 
O- O/E : patient is on mechanical ventilator
          PEEP- 6
          FiO2 - 25% 
          VT - 400ml
          Timp : 1.9
          VITALS:
temp- Afebrile
BP: 130/90mm hg @NORAD 4ml/hr
PR: 112 bpm. 
RR: 14cpm 
GRBS: 157mg/dl
spo2: 99% with Fio2 25%
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils : NSRL
GCS: E2VTM2
cough reflex: present
corneal reflex : present
conjunctival reflex: present
doll's eye: negative
REFLEXES : right. left 
       Biceps   3+                   3+
       Triceps . 3+                  3+
    Supinator  3+                 3+
       Knee        3+              3+ 
      Ankle      3+                 3+
      Plantar    extensor    extensor

A: Seizures secondary to ? tuberculoma/?NCC with severe hypoxic ischemic injury with post CPR status day 13, mechanical ventilator day 12






No comments:

Post a Comment

Internship assessment

 This blog is made based on my experience that showcases my competency and pitfalls UNIT duties —-First 15 days (12/12/22-26/12/22)         ...