Curious case of 55 year old male with seizures

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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