blog 1

 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 patient's 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

55 year old male who is a farmer came to casuality with alleged history of seizure activity on 28/2/22 for which he was admitted in a hospital where he was resuscitated and intubated after having cardiac arrest on day 2 (4 am) of his stay at the hospital.

HISTORY OF PRESENTING ILLNESS : 

Patient was apparently asymptomatic 6 years back then he suffered with sudden onset seizure activity which lasted for 8- 10 minutes ON 28/2/2022 . 

He had h/o involuntary movements of upper limb and lower limb with uprolling of eyes along with aura ,involuntary micturition and defecation, tongue bite, post ictal confusion.

He was rushed to a nearby hospital and was treated conservatively .During the stay in the hospital patient had cardiac arrest on day 2 of admission at 4 a.m. was intubated and put on mechanical ventilator and referred to us in view of of their affordability issues. 

History of fever since 3 days.

PAST HISTORY:

k/c/o seizures since 6 years.

History of trauma to head 10 years back (fall from bike ) ,no chief complaints of LOC, headache, seizures giddiness.

H/o seizure attack 6 years back for which he was treated with levipril.

1 year back he had another seizure activity since then he was advised to take regular medication ( levipil) to avoid future seizure activity but the patient didn't take regular medication.

Not a known case of DM and HTN. 

PERSONAL HISTORY: 

Alcoholic since 15 years , tobacco smoking since 30 years

GENERAL EXAMINATION:

O/E : patient is on mechanical ventilator

         FiO2 - 40%

          PEEP- 5

           VT - 420

          GCS: E1 VT M2

Pallor - present

Icterus absent

Cyanosis - absent

Edema of feet - present

Lymphadenopathy - absent

Clubbing - absent

VITALS:

Temperature: 100 F

 BP: 140/80mmhg 

  PR: 112 bpm 

  RR : 18CPM

   SYSTEMIC EXAMINATION:       

CNS:

Pupils - B/L NSRL

Reflexes:            

      Biceps 2+ 2+

      Triceps 2+ 2+

      Supinator 2+ 2+

      Knee 3+ 3+

      Ankle - -

      Plantar flexion flexion

CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard 

RESPIRATORY SYSTEM : BAE present

P/A : soft

INVESTIGATIONS:

5/3/22

BGT: B POSITIVE

SPOT URINE PROTEIN: 7

SPOT URINE CREATNINE: 74

RATIO: 0.09

PROVISIONAL DIAGNOSIS:

 SEIZURE UNDER EVALUATION (? ALCOHOL WITHDRAWAL SEIZURE) ? HYPOXIC ENCEPHALOPATHY POST CPR STATUS DAY 5 

TREATMENT: 

HEAD AND ELEVATION UP TO 30%

INJ. MEROPENEM 1 G IV BD

 INJ. LEVIPIL 500 MG IV BD 

INJ MIDAZOLAM 10 MG IN 50 ML NS @ 30 ML/ hr INJ. MANNITOL 100 ML IV BD

INJ. PANTOP 40 MG IV OD

INJ. NEOMOL 100 ML IF TEMPERATURE > 101 F INJ THIAMINE 2 AMP IN ONE DNS IV BD

SOAP NOTES:

DAY 2(7/3/22)

S:- Fever spikes present  

O: patient is on mechanical ventilator

          PEEP- 5

          FiO2 - 40% 

          VT - 400ml

          VITALS:

temp- febrile

BP 140/80 mm hg 

PR 130 bpm. 

RR 18 cpm 

spo2: 92% with Fio2 40%

CVS - S1, S2 heard ,muffled heart sounds

R. :- NVBS Present, no crepts

P/A: soft, non tender 

CNS: Pupils :B/L NSRL 

REFLEXES : right. left 

       Biceps 2+ 2+

       Triceps . 2+ 2+

    Supinator 2+ 2+

       Knee - - 

      Ankle - -

   Plantar mute mute

A:- Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR

status day 7 , mechanical ventilator day 6

nS:- no fever spikes

O- O/E : patient is on mechanical ventilato

          PEEP- 

          FiO2 - 40%

          VT - 400m

          Timp : 2.

          VITALS

temp- afebril

BP: 110/90mm hg

PR: 115 bpm.

RR: 16 cpm

spo2: 99% with Fio2 40

GRBS: 168 mg/d

CVS - S1, S2 heard ,no murmur

RS. :- NVBS Present, no crept

P/A: soft, non tender

CNS: Pupils :B/L NSRL

GCS: E1VTM

Cough reflex presen

corneal reflex presen

conjunctival reflex presen

REFLEXES : right. left

       Biceps   2+                   

       Triceps . 2+                  2

    Supinator  2+                 2

       Knee        3+              3+

      Ankle      -                  

      Plantar    mute    mut

A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 8 , mechanical ventilator day 

P: ENT opinion i/v/o tracheostom

y7e- ++- ttt2  ssl%   e:1l 5r

S:- fever spikes present

O- O/E : patient is on mechanical ventilator

          PEEP- 5

          FiO2 - 40% 

          VT - 400ml

          Timp : 2.1

          VITALS:

temp- 100.9 F

BP: 120/90mm hg @ NORAD 6ml /hr

PR: 114 bpm. 

RR: 16 cpm 

spo2: 99% with Fio2 40%

GRBS: 129 mg/dl

CVS - S1, S2 heard ,no murmurs

RS. :- NVBS Present, no crepts

P/A: soft, non tender 

CNS: Pupils :B/L NSRL 

GCS: E1VTM1

Cough reflex present

corneal reflex present

conjunctival reflex present

REFLEXES : right. left 

       Biceps 2+ 2+

       Triceps . 2+ 2+

    Supinator 2+ 2+

       Knee 3+ 3+ 

      Ankle - -

      Plantar extensor extensor

A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 9 , mechanical ventilator day 8