Deepikaroll31

GM CASES 
14/06/2021
Date of admission: 14-06-2021

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. Deepika(Internee)
Dr. Jyothna (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


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

Popular posts from this blog

Deepika rollno31

Image
40 year old male with ? acute pancreatitis  e log book to discuss our patient de-identified health data identified health data shared after taking his/her/guardians signed informed consent. 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.  A 40 year old male came to the casuality on 19 July  with chief complaints of abdominal pain since morning and vomitings since evening 5pm. History of present illness: Patient was apparently asymptomatic 3 years back. Then developed abdominal pain and vomitings and was diagnosed as acute interstitial pancreatitis. For which, he received treatment in the hospital (KIMS) for 1 week.  Patient had similar complaints of abdominal pain, vomitings, constipation 1 year back.  Pain abdomen: Site - epigastric region, pric
Read more

Surya krishna

Image
75 yr old female with low back ache, pedal edema and sob.  September 21, 2021 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 available 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-centered 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.  Case:- 75 yr old female came to the casualty with  c/o low back ache since 4 days . C/o bloating sinc
Read more