40Y/M C/O INVOLUNTARY MOVEMENTS OF B/L UL AND LL

CBBLE UDHC SIMILAR CASES

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

Informant : Patients wife and son

 A 40Y/M who is a farmer by occupation was brought to the casualty with c/o involuntary movements of B/L upper limbs and lower limbs ,GTCS type ,not associated with uprolling of eye, tongue bite, involuntary micturition/defecation.

3 episodes in a day,and was taken to a local hospital and was treated conservatively.

No similar complaints in the past

No c/o headache ,head trauma, Loc, chest pain, palpitations

Past history:-N/k/c/o Dm/htn/epilepsy/ CAD/Ba/thyroid disorders.

H/o jaundice 1 month ago for which he went to local practitioner.

Personal history:-

Married

Occupation: Farmer

Diet - Mixed,

Appetite -Normal ,

Bowel Movement - Regular 

Bladder movements: Normal

No Known Drug Allergies

H/o alcohol consumption -Regularly 300ml since 20 yrs

H/o smoking since 20 years(3 packs/day)

No habit of other addictions

Family History: Not Significant

O/e:

Patient is conscious, coherent, cooperative 

No signs of Pallor, icterus, Cyanosis, Clubbing, Lymphadenopathy,Pedal Edema

Temp:98.5°F

Pr:99bpm

Rr:18cpm

Bp:110/80

Spo2: 99% at RA

GRBS: 24mg/dl --> 25%D--> 264mg/dl

SYSTEMIC EXAMINATION

Cvs: S1 S2 +, no murmurs

Rs: BAE +,NVBS heard

PA: soft,non tender 

CNS:-

Patient is conscious  

Speech is normal

No signs of meningeal irritation

Crania nerves- NAD 

Motor system: NAD

Sensory system: NAD

Gcs:- E6V2M6

                     - RIGHT                LEFT

PUPIL.       NSRL.                      NSRL

TONE UL NORMAL              NORMAL

             LL NORMAL             NORMAL

POWER UL NORMAL          NORMAL

               LL NORMAL          NORMAL                    

REFLEXES  

       a) BICEPS 2+                2+

       b) TRICEPS 2+              2+ 

       c) SUPINATOR 2+        2+

       d) KNEE 2+                   2+

       e) ANKLE 2+                 2+

      

Provisional diagnosis:- Alcohol withdrawal seizures

INVESTIGATIONS:-

HEMOGRAM

HB: 7.6

TLC: 7,700

N/L/E/M/B: 78/16/00/06/00

PCV: 22.8

MCV: 102.7

MCH: 34.2

MCHC:33.3

RBC: 2.22

PLT: 1.40

RBC: 2.22

PS: NC/NC With mild thrombocytopenia

RFT:

BLOOD UREA : 5.3 MG/DL

SERUM CREATININE: 2.7

SERUM ELECTROLYTES:

Na+ : 139

K+: 3.4

Cl-: 101

Ca: 8.1 

LFT

TB:0.56

DB: 0.17

SGOT:142

SGPT: 51

ALP: 190

TP: 4.7

ALBUMIN: 2.44

A/G: 1.08

SEROLOGY: NEGATIVE

RTPCR:- negative

FBS 122

HBA1C : 6.8%

ECG: 

CXR

2D ECHO: https://youtu.be/wFy9kCgDhVY

EF: 55%

TRIVIAL TR+ / AR + / NO MR

NO RWMA , NO AS/MS, SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION + 

NO DIASTOLIC DYSFUNCTION, NO PAH/PE

PLAN:-

1. 25% Dextrose IVF /IV/STAT

2. IVF 1 NS With 2 amp of thiamine/Iv/stat

3.IVF 5%Dextrose/Iv/Stat

4.IVF- NS, RL , DNS@ 100ML/HR

5.IVF 1 NS -2AMP of thiamine/IV/TID

6.Inj. pantop 40mg /iv/od

7. Inj.lorazepam 2cc/iv/SOS

8. Inform seizure activity

9.Monitor vitals hrly and grbs hrly

                            SOAP NOTES

DAY 1

AMC BED 3

S: no fever spikes  

 no fresh complaints

O:

O/e

Patient is c/c/c

Temp:Afebrile

Pr:86bpm

Rr:19cpm

Bp:140/90

Spo2:94% at RA

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender, Bs +

GRBS: 117mg/dl

A: ? Hypoglycaemic Seizures  

(Whipples triad:

+ Symptoms of hypoglycemia

+ Resolution of symptoms after glucose

+ Low plasma glucose level )

P: 

1.IVF- NS, RL , DNS@ 75ML/HR

2. IVF 1 NS With 2 amp of thiamine/Iv/tid

3.Inj. pantop 40mg /iv/od

4.Inj. zofer 4mg /iv/sos

5.Tab. Librium 5mg/po/bd

6. Inform seizure activity

7.Monitor vitals hrly and grbs charting hrly

Plan for USG abdomen and psychiatry referral I/v/o alcohol dependence

CRP:  NEGATIVE

ESR: 15MM

WARD UPDATE 

DAY 2

S: no fever spikes  

 C/o pedal edema since yesterday night( pitting type)

O:

O/e

Patient is c/c/c

Temp:Afebrile

Pr:92bpm

Rr:17cpm

Bp:110/80

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender, Bs +

GRBS: 152mg/dl

A: Hypoglycaemic seizures

P: 

1.IVF- NS, RL , DNS@ 75ML/HR

2. IVF 1 NS With 2 amp of thiamine/Iv/tid

3.Inj. pantop 40mg /iv/od

4.Inj. zofer 4mg /iv/sos

5.Tab. Librium 25mg/po/bd

6. Inform seizure activity

7.Monitor vitals hrly and grbs charting 4th hrly

8.2 egg whites /day

9.2 tbsp of protein in 1 glass of water/milk /po/tid

Plan for usg abdomen i/v/o pain abdomen

Plan to discharge

Advice at discharge 

1.Plenty of water

2.T.pan 40mg Po/OD/BF X 5D

3.T.MVT PO/OD X 2 WEEKS

45Y/F WITH C/O GENERALISED WEAKNESS SINCE 2 DAYS

 CBBLE UDHC SIMILAR CASES

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

45 years old P3L3 female, agricultural labourer by occupation, came to the casuality with C/O generalised weakness since 2 days.

H/O vomitings and loose stools 2 days back.

HOPI:

Patient was apparently asymptomatic 1 year back and then had H/O Neck pain and backache - dragging type of pain, not associated with any numbness, tingling sensation of upper and lower limbs.

Patient started taking NSAID daily once for pain for 1 month, then she visited orthopaedician and advised her to get MRI: L-Spine and after that she was advised for surgery.

Patient had difficulty in passing stools (constipation) since 1 month for which the patient went to the nearby doctor 2 days back.

She was put on Syp. Lactulose and after 1 day, the patient had 5 episodes of watery stools for 1 day, 2 episodes of vomitings for 1 day which subsided now.

Generalised weakness present since 2 days.

PAST HISTORY:

Not a K/C/O DM/HTN/BA/TB/Epilepsy/Thyroid disorders/CAD/CVA

Patient underwent ECSL for Right Renal stones (ECSL) 6 years back, Hysterectomy 20 yrs back and Left Cataract Surgery 6 yrs back.

PERSONAL HISTORY:

Diet- mixed

Appetite- Normal

Sleep- Adequate

Bowel and bladder movements- Regular

No known allergies

No addictions

Family history: not significant

GENERAL EXAMINATION:

Patient is Conscious, coherent, cooperative.

No Pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.

Vitals:

Temp.- Afebrile

BP- 110/70 mmHg

PR- 100 bpm

RR- 12 cpm

SpO2- 98%

GRBS- 138 mg/dL

SYSTEMIC EXAMINATION:

CVS- S1 S2 heard, no murmurs

RS- BAE+ NVBS+

P/A- Soft, Non-tender

CNS- 

Patient is Lethargic

GCS- 15/15

Sensory and motor systems - Intact

Cranial nerves- intact

Reflexes- Intact

INVESTIGATIONS

USG ABDOMEN:

CHEST X-RAY PA VIEW:

X-RAY L-SPINE:

X-RAY L-SPINE Report :

C-Reactive protein: Positive on DOA:5 (2.4 mg/dL)

RFT on DAY 6

PROVISIONAL DIAGNOSIS:

AKI on CKD secondary to ?anagesic neuropathy

Pyrexia under evaluation

TREATMENT GIVEN:

1. IV Fluids NS and RL @ UO+50 ml/h

2. Inj. Optineuron 1 amp in 100 ml NS

3. Inj. PANTOP 40 mg IV OD

4. Inj. Lasix 20 mg IV BD (if sBP>110 mmHg)

5. Inj. Neomol 100 ml IV SOS (if temp>101 F)

6. Tab. PCM 500 mg PO SOS

7. GRBS - 6th hrly

8. I/O Charting

9. Monitor vitals 4th hrly

Orthopedics referral:

Nephrology Referral:

SOAP NOTES:

Day 2 

S: 

Generalised weakness present

No fresh complaints

O:

Temp.- Afebrile

BP- 120/70 mmHg

PR- 98 bpm

RR- 18 cpm

SpO2- 97% at RA

GRBS- 103 mg/dL

A:

Viral Pyrexia with Thrombocytopenia

AKI secondary to ?Sepsis

P:

1. IVF - NS,RL,DNS @ UO+100 ml/h

2. Inj. PANTOP 40 mg IV OD

3. Inj. Zofer 4 mg IV SOS

4. Inj. Lasix 40 mg IV BD (if sBP>110 mmHg)

5. Inj. Neomol 100 ml IV SOS (if temp>101 F)

6. Tab. PCM 500 mg PO/SOS

7. Tab. Doxycycline 100 mg PO/BD

8. Monitor vitals 4th hrly

9. I/O and Temp. Charting

Day 3

S:

C/o burning micturition, nausea (+), decreased appetite, 

No h/o fever, vomitings

O:

Pt is C/C/C

Temp- afebrile

Bp- 120/70 mmhg

PR- 74bpm

RR- 16cpm

SPO2- 99% 

CVS- S1 S2 heard

Rs- BAE+

CNS- NFND

P/A- Soft, Non-tender

A:

Viral pyrexia with thrombocytopenia

AKI secondary to ?GE 

With UTI secondary with R renal calculi

P:

1. IVF- NS RL DNS UO+ 50ml/hr

2. Inj. Optineuron 1amp in 100ml NS IV/OD

3. Inj. Pantop 40mg IV OD

4. Inj. Zofer 4mg IV OD

5. Inj. Neomol 1amp in 100ml NS IV if temp >101F

6. T. PCM 500mg PO/SOS

7. Temperature and I/O charting

8. Vitals monitoring

Day 4 

S:

C/o burning micturition, nausea (+) decreased appetite, 

No h/o fever, vomitings

O:

Pt is C/C/C

Temp- afebrile

Bp- 110/70 mmhg

PR- 72 bpm

RR- 17 cpm

SPO2- 98% 

CVS- S1 S2 heard

RS- BAE+

CNS- NFND

P/A- Soft, Non-tender

A:

Viral pyrexia with thrombocytopenia

AKI secondary to ?GE 

With UTI secondary with R renal calculi

P:

1. IVF- NS RL DNS UO+ 50ml/hr

2. Inj. Optineuron 1amp in 100ml NS IV/OD

3. Inj. Pantop 40mg IV OD

4. Inj. Zofer 4mg IV OD

5. Inj. Neomol 1amp in 100ml NS IV if temp >101F

6. T. PCM 500mg PO/SOS

7. Temperature and I/O charting

8. Vitals monitoring

Day 5 

S:

C/O decreased appetite and nausea+

No fever spikes

O:

Pt is C/C/C

Temp- Afebrile

Bp- 110/80 mmhg

PR- 82 bpm

RR- 18 cpm

SPO2- 99% 

CVS- S1 S2 heard

RS - BAE+

CNS- NFND

P/A- Soft, Non-tender

A:

Viral pyrexia with thrombocytopenia

AKI secondary to ?GE 

With UTI secondary with R renal calculi

P:

1. IVF- NS RL DNS UO+ 50ml/hr

2. Inj. Optineuron 1amp in 100ml NS IV/OD

3. Inj. Pantop 40mg IV OD

4. Inj. Zofer 4mg IV OD

5. Inj. Neomol 1amp in 100ml NS IV if temp >101F

6. Inj. Lasix 40 mg IV BD if sBP>110 mmHg

7. T. PCM 500mg PO/SOS

8. T. Doxycycline 100 mg PO/BD

9. Syp. Lactulose 15 ml PO/HS

10. Syp. Aristroxyme 15 ml PO/TID

11. Syp.Cremaffin 5ml PO/TID HS

12. Temperature and I/O charting

13. Vitals monitoring

14. GRBS monitoring 12 th hrly

59Y/F with hyponatremia

CBBLE UDHC SIMILAR CASES

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

A 59Y/F  brought to the casualty with c/o involuntary movements of B/L upper limbs and lower limbs ,GTCS type , with uprolling of eye, tongue bite, involuntary micturition, lasting for 2.min , with post ictal confusion + ,aura -.

H/o vomitings, (4-5 episodes in a day), nonbilious, non projectile, food particle as content

H/o pain abdomen since yesterday diffuse type, 

No c/o cold, cough, fever, burning micturition, headache ,trauma, Loc.

Past history:-N/k/c/o Dm/htn/epilepsy/ CAD/Ba/thyroid disorders.

Personal history:-

Married

Occupation Housewife

Diet  - Mixed,

Appetite -Normal ,

Bowel Movement - Regular 

Bladder movements: Normal

No habit of  addictions

No Known Drug Allergies

Menopause attained

Family History: Not Significant

O/e:

Patient has altered sensorium 

No signs of Pallor, icterus, Cyanosis, Clubbing, Lymphadenopathy,Pedal Edema

Vitals;-

Temp:98m5

Pr:89bpm

Rr:17cpm

Bp:140/80

Spo2:97% at RA

GRBS: 160mg/dl

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender

Cns:-

Patient is conscious but drowsy 

Speech  is incoherent

No signs of meningeal irritation

Cranial nerves- NAD 

Motor system: NAD

Sensory system: NAD

Gcs:- E4V2M6

                           -         RIGHT               LEFT

PUPIL.                    NSRL.               NSRL

TONE         UL        NORMAL       NORMAL

                     LL        NORMAL       NORMAL

POWER    UL         NORMAL       NORMAL

                    LL         NORMAL       NORMAL                    

REFLEXES  

       a) BICEPS               2+                    2+

       b) TRICEPS            2+                    2+ 

       c) SUPINATOR       2+                    2+

       d) KNEE                   2+                    -

       e) ANKLE                 2+                    2+

       f) PLANTAR        extensor          extensor

Investigations:- 

ABG

PH  7.44

PCO2 24.0

PO2 107

HCO3 16.1

ST HCO3 20.0

HEMOGRAM: 

HB: 13.5

TLC: 16,800

N/L/E/M/B: 86/09/01/05/00

PCV: 38.1

MCV: 80.8

MCH: 28.6

RBC:4.72

RDW-CV :12.6

RDW-SD: 41.7

PS: NC/NC

PLT:-1.1

CUE-

Alb :+

Sugars:nil

Pc:4-5/Hpf 

RBS 164mg/dl

SERUM ELECTROLYTES

Blood Urea : 16 MG/DL

Serum Creatinine: 0.7

Serum calcium:10.9

Serum phosphate: 2.4

LFT

TB: 1.35

DB: 0.3

SGOT:19

SGOT:25

ALP: 163

TP:7.6

ALBUMIN:4.9

A/G: 1.87

SER.LIPID PROFILE: 

Total cholesterol:171mg/dl

Triglycerides: 153mg/dl

HDL: 48

LDL:98

VLDL:30

TFT(3/3/22):

T3:0.71

T4;9.10

TSH:4.91

SPOT URINE SODIUM 122

SPOT URINE POTASSIUM 21.0

URINARY CHLORIDE 15

SERUM FOR OSMOLALITY 269

RTPCR: NEGATIVE

SEROLOGY: NEGATIVE

ECG: 

CXR

2D ECHO:   https://youtu.be/vwqwpJczZvg

TRIVIAL TR+ / AR+ / NO MR

GOOD LV SYSTOLIC FUNCTION + 

NO RWMA , NO AS/MS , SCLEROTIC AV

DIASTOLIC DYSFUNCTION +, NO PAH /PE

USG ABDOMEN:- IMP

Right simple renal cortical cyst

CT BRAIN IMP-No abnormality detected in brain

Diagnosis :- Seizures secondary to hyponatremia

Plan:-

1)Inj. levipril 1 gm in 100ml Ns iv stat

2)inj. pan 40mg iv stat

3)3% Nacl infusion @ 10ml/hr followed by 4th hrly serum electrolytes

4)0.9 % Ns @ 75ml/hr

5)Strict I/O charting

6)Monitor vitals hrly

                                 

                                SOAP NOTES

DAY 1:

Amc Bed 8

Day 1

59yr/F

S: 2 fever spikes  

 

O:

O/e

Patient is c/c/non cooperative

Temp:Afebrile

Pr:89bpm

Rr:17cpm

Bp:120/70

Spo2:97% at RA

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender

CNS: E4V5M6

Pupils : B/l Nsrl

                     RIGHT               LEFT

PUPIL.          NSRL.                NSRL

TONE UL NORMAL        NORMAL

              LL NORMAL        NORMAL

POWER UL NORMAL     NORMAL

                 LL NORMAL     NORMAL                    

REFLEXES  

       a) BICEPS 2+               2+

       b) TRICEPS 2+            2+ 

       c) SUPINATOR 2+       2+

       d) KNEE         -.            -

       e) ANKLE     2+             2+

       f) PLANTAR extensor extensor

Didn't pass stools

GRBS: 100mg/dl

A: Seizures secondary to chronic hyponatremia (hypovolemia- resolved) 

P:

1.Ivf - 3%  Nacl @ 15ml/hr to be I/D A/to sr.electrolytes 4th hrly   

2.inj monocef 1gm/iv/bd

3.inj pan 40mg/iv/od

4.inj zofer 4mg/iv/sos

5.inj neomol 100ml /iv/ if temp > 101.1°F

6.Monitor vitals 2nd hrly

7.Head end elevation upto 30°

6PM:- 

3%Nacl stopped

0.9% Nacl @ 50ml/hr

 

DAY 2 

Amc Bed 8

Day 2

59yr/F

S: no fever spikes  

 no fresh complaints

O:

O/e

Patient is c/c/c

Temp:Afebrile

Pr:89bpm

Rr:17cpm

Bp:140/90

Spo2:97% at RA

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender

Didn't pass stools

GRBS: 114mg/dl

A: Seizures secondary to chronic hyponatremia (hypovolemia- resolved) 

P:

1.Ivf - 1 Ns with 1 amp of optineuron /iv/od

2.inj monocef 1gm/iv/bd

3.inj pan 40mg/iv/od

4.inj zofer 4mg/iv/sos

5.inj neomol 100ml /iv/ if temp > 101.1°F

6. Syp cremaffin 10ml.tid

7.Monitor vitals 2nd hrly

Ward update

Day 3

59yr/F

S: no fever spikes  

 no fresh complaints

no pain abdomen

O:

O/e

Patient is c/c/c

Temp:Afebrile

Pr:80bpm

Rr:19cpm

Bp:130/70

Spo2:99% at RA

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender

Didn't pass stools

GRBS: 151mg/dl

A: Seizures secondary to hyponatremia (hypovolemia- resolved) 

P:

1. Plenty of oral fluids

2.T.pcm 500mg/po/od

3.T.pan 40mg/po/od

4.syp.mucaine gel /po/bd

5. Syp cremaffin plus po/hs

6.Monitor vitals 4th hrly

Ward update

Day 4

59yr/F

S: no fever spikes  

 no fresh complaints

no pain abdomen

O:

O/e

Patient is c/c/c

Temp:Afebrile

Pr:86bpm

Rr:17cpm

Bp:120/70

Spo2:98% at RA

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender

GRBS: 136mg/dl

A: Seizures secondary to hyponatremia (hypovolemia- resolved) 

P:

1. Plenty of oral fluids

2.T.pcm 500mg/po/od

3.T.pan 40mg/po/od

4.syp.mucaine gel /po/bd

5. Syp cremaffin plus po/hs

6.Monitor vitals 4th hrly