Saturday, July 22, 2023

A 43 year old male with SEIZURES

Saturday, July 8, 2023

43 YEAR OLD MALE WITH SEIZURES


Introduction: Welcome to my blog! I am U.AKANKSHA a 4th year medical student.This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs.It also reflects patient centered online learning portfolio.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.
Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 


A 43 year old male was brought to the casualty with comlains of involuntary movements of body since today morning. 

HISTORY OF PRESENTING ILLNESS
The Patient was apparently asymptomatic 4 days back when he had a binge of alcohol . he lost consciousness at his workplace and was taken to the hospital. At the hospital, the correction fluids were given and the patient was sent home. Today morning he had 2 episodes of involuntary movement of body (tonic movements with stiffening of body) lasting 1-2 minutes and relieved on itself. 
His wife checked his grbs at home after this episode and it was found to be 60mg/dl after which he was rushed to the hospital. In the hospital the correction was done inspite of which involuntary movements continued. He was then brought to our hospital. 
No uprolling of eyes or loss of consciousness during the episodes.
No c/o vomitings, headache, frothing from mouth, deviation of mouth, tongue bite, post ictal confusion, involuntary micturition/defecation.

PAST HISTORY:
No similar complains in the past.
K/C/O DM-II since 5 years on insulin. He was diagnosed with DM-II Incidently during an episode of fever for which he was initially prescribed OHA'S. The patient used to skip taking his medication. Due non compliance and very high sugars he was then shifted to insulin. 
N/k/c/o HTN, CVA, CAD, Bronchial asthma, thyroid disorders. 

DAILY ROUTINE :
The patient works as an attender in a college.
He lives with his wife and three children.
He doesn't always follow his routine and go to the college.
He gets up in the morning and freshens up and has breakfast. After his family leaves for work/college, he either goes to college or goes out with his friends and drinks alcohol. 
He often skips meals  as he forgets about them while he is drinking alcohol. He often consumes food late at night when he is very hungry. 
The alcohol consumption has increased in the last 1 year. 
On enquiring about the reason of chronic alcoholism with his family, they say that they can't think of any triggers as such. 


PERSONAL HISTORY
Diet: mixed 
Appetite: lost
Sleep: adequate 
Bowel: regular 
Micturition: normal 
Addictions: drinks alcohol since 20 years, chews gutka since 1 year 
Allergies: nil

Family history: not significant

GENERAL EXAMINATION
Patient is examined in a well lit room after taking an informed consent. 
Patient is conscious and coherent. 
No signs of pallor, icterus, clubbing, cyanosis, generalized lymphadenopathy, pedal edema 


VITAL AT THE TIME OF ADMISSION: (09/07/23) 

Temp: 98F
Pulse: 114bpm
RR: 20cpm
Bp:100/80 mm of hg 
Spo2: 99% at RA
Grbs: 

Systemic examination:

CNS EXAMINATION
GCS: 15/15
The patient is conscious. 
Speech: normal
Cranial nerves: intact 
Seonsory system: normal 
Motor system: 
                       UL                       LL
Tone R INCREASED       INCREASED
          L INCREASED       INCREASED

POWER
          R      5/5                        5/5
          L       5/5                        5/5


REFLEXES           R                       L
BICEPS               2+                      2+
TRICEPS             1+                      1+
SUPINATOR        0                         0
KNEE                    0                         0
ANKLE                  0                         0
PLANTAR             E                         E


RESPIRATORY SYSTEM EXAMINATION 
-Bilateral air entry is present, normal vesicular breath sounds heard. 

CARDIO VASCULAR SYSTEM
S1 and S2 are heard. No murmurs are heard

ABDOMINAL EXAMINATION:
Soft, non-tender. 
No organomegaly
Bowel sounds are heard. 

INVESTIGATIONS:-

USG ABDOMEN

X-RAY CHEST


EEG 


ECG


PROVISIONAL DIAGNOSIS: SEIZURES UNDER EVALUATION SECONDARY TO ? HYPOGLYCEMIA ? TOXIN MEDIATED


INVESTIGATIONS: 

9/07/23
SERUM ELECTROLYTES: 
Na: 145
K: 3.2*
Cl: 99
Ca2+: 1.13
Mg2+: 2

Blood urea 20mg/dl
S. Creatinine: 1 mg/dl
RBS: 130MG/DL

LFT:
total billirubin : 0.98mg/dL
Direct bilirubin: 0.20 mg/dL
AST: 45 IU/L
ALT: 30IU/L
ALP: 301* IU/L
Total proteins: 7 gm/dL
Albumin: 4 gm/dL
A/G ratio: 1.25

Hemogram:
Hb: 10.9gm/dL*
Total count: 6,400cell/mm3*
N/L/E/M/B: 75/18*/2/5/0
PCV: 34.6 vol%*
MCV: 78.6fl*
MCH: 24.8pg*
MCHC: 31.5%
RDW-CV:18.2%*
RBC COUNT: 4.40 millions/mm3*
PLATELET COUNT: 1.92lakhs/mm3
Smear
RBC: normocytic normochromic 


TREATMENT GIVEN
INJ. LORAZEPAM 2CC IV/STASTAT
INJ. LEVIPIL 1GM IN 100ML NS IV/STAT
INJ. SODIUM VALPROATE 300MG IN 100ML NS IV/BD
INJ. HAI S/C ACCORDING TO GRBS
INJ. THIAMINE 1AMP IN 100ML NS IV/BD
SYP. POTCLOR 15ml IN 1 GLASS OF WATER



10/7/23
FBS: 192 MG/DL
PLBS: 294 MG/DL
HBA1c: 6.5%

HEMOGRAM
Hb: 9.7gm/dL*
Total count: 7,800 cell/mm3*
N/L/E/M/B: 70/20*/4/6/0
PCV: 30.2 vol%*
MCV: 70.8FL*
MCH: 25.1pg*
MCHC: 32.1%
RDW-CV:18.2%*
RBC COUNT: 3.8millions/mm3*
PLATELET COUNT: 2lakhs/mm3
Smear
RBC: normocytic normochromic 

SERUM ELECTROLYTES: 
Na: 139
K: 3.5*
Cl: 101
Ca2+: 1.24


A 65 year old male with PAIN DISTENDED ABDOMEN and PAIN IN RT CHEST since 1 yr

65 year old male from beemanapally

Introduction: Welcome to my blog! I am U.AKANKSHA a 4th year medical student.This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs.It also reflects patient centered online learning portfolio.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

Date of admission 21/7/23

65 yr old male agricultural labourer by occupation came to OPD with C/O abdominal pain, lower back pain radiating to b/l lower limbs, neck pain with stiffness since 1 year. 

History of present illness:

Patient was apparently asymptomatic 1 year ago later he developed pain in abdomen which
Insidious in onset gradually progressive. It is diffuse and dull causing discomfort.It is aggravated on eating,performing daily activities and walking.

Pain in the chest is lasts for 2-5 min which is sudden in onset.It is relieved by massaging that particular area.

Yesterday night patient complained of pricking type of headache due to dental carries on the right lower molars due to which he was unable to sleep. 

Past illness:
Diabetes since 15 years.
Not a K/C/O  HTN, TB, asthma, epilepsy or any other chronic illness.
TRAUMA :
4 years back, then he had a fall while taking his cattle to the field due to which the patient experienced severe pain in the right hip and was unable to walk. 
Right hemiarthroplasty was done immediately. 
Since 1 yr the patient gradually developed backache and dragging type of pain in b/l lower limbs.
 He had difficulty in bending, difficulty in getting up from sitting position, joint stiffness+.

Drug history 
Insulin injections twice daily

Personal history 
Diet mixed 
Sleep is adequate 
Appetite decreased
Bowel and Bladder: normal
No Allergies 
Addiction: alcohol occasionally once in few weeks

Daily routine
The patient wakes up at 5 am and gets ready.
He generally prefers to have roti and curries for his breakfast.

After that he sleeps for few hours.
His lunch items includes rice and vegetables, mostly around 1pm.
Then he goes outside for a walk in the evening and is back by 8pm for dinner.

Patient is an agricultural labourer but has left his job since he was diagnosed with diabetes that is 15 years back.

General examination

Patient is conscious, coherent and cooperative and well oriented to time place and person.

No pallor, icterus, cynosis, clubbing,edema, lymphedenopathy 

Vitals

Pulse rate-68 bpm
Blood pressure- 130/80mm Hg
Respiratory rate- 16cpm
CVS- S1S2 +, no murmurs
RS- BLAE +, NVBS heard














Investigations

Ultrasound 


ECG


2D ECHO




TREATMENT:-

Biphasic insulin 
Pantoprazole 40mg
Multivitamin tablets


A 60 F with pedal edema since 1 week and facial puffiness

Introduction: Welcome to my blog! I am U.AKANKSHA a 4th year medical student.This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs.It also reflects patient centered online learning portfolio.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.
Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

CASE:-

A 60 year old female, who was an agricultural labourer by occupation (but has stopped working since 4 years), came to the hospital with complaints of pain in both knees since 4-5 years, facial swelling since 2-3 months, pedal edema since 1 week.

HISTORY OF PRESENTING ILLNESS:-

The patient was apparently asymptomatic 4-5 years ago. She then started developing pain in both her knees which is aggravated on walking and standing, relieved on resting and medications (painkillers). She stopped working due to the pains.

2-3 months ago, she developed facial puffiness which was insidious in onset and gradually progressive in nature. It appears maximally in the mornings and gets relieved by the end of the day. 

1 month ago, she had a tooth extraction on the left side and still has facial puffiness on the left side.

1 week ago, she had pedal edema upto her ankles which was pitting in nature. This also appears maximally in the morning and subsides by the end of the day. Her edema greatly subsided by itself after a week.
She came to the hospital now to find a working solution for her joint pains and to find out about why her pedal edema appeared and disappeared.

DAILY ROUTINE:-

The patient wakes up in the morning at 5:30 and begins household chores, eats breakfast at 8:00. She smokes tobacco at this time.

She then passes her time by talking with family members or guests till 11:00, when she cooks her lunch and eats lunch late, around 3:00-4:00pm

She has tea occasionally in between, when she visits family. She spends time sleeping or talking with friends and family in person or on the phone.

At night, she doesn't feel hungry. She may or may not smoke tobacco again. She then sleeps at around 10:00pm.


PAST HISTORY:-

Not a known case of diabetes, hypertension, CVA, CAD, TB, asthma

FAMILY HISTORY:-

Not significant.

TREATMENT HISTORY:-

The patient has a history of using NSAIDS 3-4 days a week since 4 years for the joint pains, suggested by and RMP.

PERSONAL HISTORY:-

Appetite: normal

Diet: mixed

Sleep: adequate

Bowel movements: regular

Micturition: normal

No known allergies

Addictions: Smokes tobacco once or twice a day everyday

MENSTRUAL HISTORY:-

Attained menopause 20 years ago

OBSTETRIC HISTORY:-

Age at marriage: 18 yrs

Age at first childbirth: 20

Obstetric formula: G5P5L5

All normal vaginal deliveries

GENERAL EXAMINATION:-

The patient is conscious, coherent, cooperative and well-oriented to time, place and person.

The patient is moderately built and well-nourished.

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy

Pedal edema present in right foot (grade 1)
Vitals:-

Temperature: Afebrile

Blood pressure: 120/80mm Hg

Pulse rate: 82 bpm

Respiratory rate: 18cpm












SYSTEMIC EXAMINATION:-

CNS: Patient is conscious, coherent and cooperative, well-oriented to time, place and person

CVS: S1, S2 sounds heard, no murmurs

Respiratory system: trachea central, normal vesicular breath sounds heard, no added sounds

Abdomen: distended, no palpable organs.



INVESTIGATIONS:-

19.07.2023:-

Ultrasound:-

ECG


PROVISIONAL DIAGNOSIS:-

Facial puffiness under evaluation

TREATMENT:-

Took Potassium citrate and magnesium citrate for pedal edema, given at government hospital.

Aspirin

Rosuvastatin

Furosemide