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
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
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
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