28 year old male patient with seizures

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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

I have 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.

Following is the view of my case...

CASE

28 year old male who is a sales man in cloth store presented to casualty with seizures 15 days back and fever with chills and cough since 10 days

HISTORY OF PRESENTING ILLNESS 

 •Patient was apparently asymptomatic 11 months back ( Feb-2021) then he noticed weight loss of about 10 kgs within 1 month

•After 2 months(April-14th ) he consulted local doctor ,on investigations there was increased in creatinine levels and hypertension

•Then went to Hyderabad for confirmation and told to start hemodialysis

•Then he came to our hospital on (april-16) for treatment then he was tested positive for covid ,so no treatment was started

•Then he came back on June 24th. then he was put on dialysis . 

•He was on regular dialysis from june 24th to September 19th, nearly 28 dialysis was completed•

•Then he decided to remove central line and shift to AV fistula , which was failed once , then he tried again so was not on dialysis for 3 months( september to december)

•Then he had SEIZURES 15 days back , where there was 3 episodes 

 - each episode of seizure lasted for 3 to 5 minutes, associated with unrolling of eyes and frothing from mouth , there was post icthal confusion for about 30 minutes after 1st episode and about 10 to 15 minute after 2nd and 3rd episode

-not associated with biting of tongue and involuntary micturition 

-after 1st episode he was taken to nearby hospital for he was admitted and treated for 3 days and was discharged and then he had another 2 episodes of seizures then he came back to our hospital , again. he was started on dialysis 

-he complaints of shortness of breath ( II- III grads) and fever ( low grade),cough( dry cough),associated with chills , decreased urine output, and decreased appetite and chest pain since 10 days

-not associated with burning micturition, hematuria, nausea, vomiting, loose stools, head aches, confusion, dizziness

PAST HISTORY

 •Known case of hypertension since 11 months

•Not a known case of diabetes, asthma, TB , any CHD

FAMILY HISTORY

 

no significant family history

PERSONAL HISTORY

 

▪Diet-mixed

▪ Appetite-decreased

▪Bowel movements-Regular

▪Bladder movements-Decreased since 10 days

▪Sleep adequate

▪Habits- he was alcoholic and stopped since 8 months, and not a smoker

GENERAL EXAMINATION

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

and person, moderately built and moderately nourished

- Pallor- present

-Icterus-absent

-Cyanosis-absent

-Clubbing-absent

-Lymphadenopathy-absent

-Edema-absent

VITALS

 Temperature-98.6

Pulse rate-88 bpm

Respiratory rate-14 com

BP-160/100 mm h

Spo2-98%

GRBS-130 mg%

 

SYSTEMIC EXAMINATION

 

▪CVS-- s1 ,s2 heard no murmurs

 • Respiratory system- normal vesicular breath sounds heard

 • Abdomen- no tenderness seen, no. . palpable mass seen, not distended

▪CNS-

 -Patient is conscious

-Speech -normal

-No signs of meningeal irritation

-SENSORY EXAMINATION,- touch, pain , vibration present

-No muscle wasting seen

-Tone of muscles is normal

▪REFLEXS:-

 

• Deep tendon reflexes

                        Right.          Left

  Knee jerk.      +2.               +2

  Ankle reflex +2               +2    

  Biceps.          +2.                 +2      

  Triceps.        +2                    +2

  Supinator.     +2.                    +2

  

•Power

Biceps.             5/5.                     5/5

Triceps.            5/5.                     5/5

Extensors of knee

                          5/5.                      5/5 

 Flexors of knee

                           5/5.                      5/5

Exetnsors of hip

                           5/5.                      5/5

Flexors of hip

                            5/5.                      5/5

    

                 

  

•Gait -normal  

▪Coordination

- Finger nose test- no incoordinatino is seen

- knee heel test- able to perform on both sides

- Romberg sign- negative

INVESTIGATIONS

  

22/12/2021

          

       

24/12/2021

25/12/2021

27/12/2021

PROVISIONAL DIAGNOSIS

 Uremic encephalopathy with ckd on mhd with hypertensive nephropathy

TREATMENT

1) Fluid restriction( 1 ltr per day)

2)salt restriction( 2.4 g per day)

3)Tab NODOSIS( 550mg )PO/OD

4)Tab SHELCAL(500 mg) PO/OD

5)Tab OROFER Po/ OD

6)Tab LASIX 40 mg PO / BD

7)TAB NICARDIA 10 mg PO/BD