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
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
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