74 year old with seizures

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 This is an online E logbook 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 an available global online community of experts to solve those patients 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 are 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 diagnosis and treatment plan.


Following is the view of my case :

Date of admission : 13/11/22

Chief complaints :

C/O INVOLUNTARY MOVEMENTS OF ALL THE FOUR LIMBS AT 1:00 AM ON 13/11/22

History of present illness : 

74 YEAR OLD WAS APPARENTLY ALRIGHT TILL YESTERDAY 1:00 am , then he SUDDENLY DEVELOPED INVOLUNTARY MOVEMENTS OF ALL 4  limbs,  frothing, uprolling of eye balls and altered sensorium for which he was brought to the hospital . There were 4 such episodes since night which lasted for 3 to 4 minutes 

Past history:

K/c/o tuberculosis 4 years back used medications for 1 year 

K/c/o diabetes from past 5 months 

N/k/c/o htn,asthama, epilepsy


Family History:

Not Significant

Personal History:

Diet - mixed

Appetite - normal

sleep - adequate

Bowel and Bladder movements -regular

Addictions - 2 packs of beedi daily, regular toddy consumption from past 50 years 

No known allergies

Drug history : 

No significant drug history


General examination :

Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person at the time of examination

He is examined in a well lit room, with consent taken.

He is moderately built and well nourished.

Pallor - mild

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent


Vitals : on the day of admission 

Temperature - afebrile

Pulse rate - 76 bpm

Respiratory rate - 16 cpm

Blood pressure - 130/90 mmHg

GRBS : 133mg%

Systemic examination :

CVS : S1 and S2 heart sounds hear

NO murmurs and thrill

RESPIRATORY SYSTEM : Bilateral air entry present             

position of trachea - central 

Vesicular breathsounds heard

CNS : 


ABDOMEN 

Soft

Non tender

No palpable mass

 Bowel sounds heard

 NO organomegaly

CLINICAL IMAGES 




INVESTIGATIONS 

 Hemogram



 
Serum electrolytes and serum ionized calcium 

Blood UREA 

Serum creatinine


 Serum calcium

Serum magnesium 

Bleeding and clotting time

HBsAg


 
Anti HCV antibiodies

Lipid profile 


Liver function test


HIV 1/2 rapid test


Complete urine examination 


USG ABDOMEN 


MRI brain 


Chest x ray


Bacterial  culture and sensitivity report



2D ECHO 






DIAGNOSIS


Generalized tonic clinical seizures under evaluation 


TREATMENT 


1.Inj.LEVIPIL 500MG IV BD


2.INJ.OPTINEURON 1AMP IN 500ML NS IV OD


3.MONITOR VITALS AND INFORM SOS

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