18-12-2024
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
https://youtu.be/LooD7oDtW8I?feature=shared
PPM 2 - UMN Quadriparesis?
PPM 1 - Yes
Bilateral internal capsular infarcts. Marked spastic hypertonia in all four limbs, hyperreflexia and bilateral planter extensor.
PPM 2 - Seems quite severe for a cortical lesion - any cord involvement? Is this MS?
PPM 1 - 👍
EMR Summary
Age/Gender : 62 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 25/09/2024 08:43 PM
Diagnosis
GTCS SECONDARY TO OHA INDUCED HYPOGLYCEMIA [ RESOLVED]
ALTERED SENSORIUM(RESOLVED) SECONDARY TO NEUROGLYCOPENIA WITH GTCS K/C/O T2DM SINCE 2 1/2 YEARS; K/C/O HTN SINCE 5 YEARS
K/C/O CVA RIGHT HEMIPARESIS 3 YEARS AGO
IRON DEFECIENCY ANEMIA SECONDARY TO NUTRITIONAL CAUSE B/L OSTEOARTHRITIS OF KNEE
Case History and Clinical Findings
CHIEF COMPLAINTS:
PATIENT BROUGHT TO CASUALITY IN UNCONSCIOUS STATE SINCE 1 HOUR HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 HOUR BACK THEN HE WAS UNRESPONSIVE,SUDDEN IN ONSET,GRADUALLY PROGRESSIVE
AFTER 15 MINUTES PATIENT HAD INVOLUNTARY MOVEMENTS OF BOTH UL AND LL WITH UPROLLING OF EYE BALLS ,NO FROTHING ,NO TONGUE BITE,NO INVOLUNTARY MICTURITION OR DEFECATION
H/O B/L PEDAL EDEMA SINCE 1 YEAR ON AND OFF Aggravated SINCE 5 DAYS PITTING TYPE UPTO KNEES
NO H/O FEVER,COUGH,COLD NO H/O CHEST
PAIN
PAST HISTORY:
K/C/O T2DM SINCE 2 1/2 YEARS ON TAB.METFORMIN 500MG PO/OD(TAKING OGLISTAR GM 1 SINCE 3 DAYS UNKNOWINGLY)
K/C/O HTN SINCE 5 YEARS ON TAB.NICARDIA 10MG PO/BD
K/C/O CVA -RIGHT HEMIPARESIS 3 YEARS AGO ON HERBAL MEDICATION N/K/C/O THYROID DISORDERS,EPILEPSY
AT TIME OF ADMISSION :
TEMP:98.6 F
BP: 170/100 MM/HG PR:136 BPM
RR:18 CPM SPO2: 98%@RA
GRBS:21 MG/DL--->25%D---.168MG/DL OEDEMA OF B/L FEET -PRESENT
NO ICTERUS, PALLOR, CYANOSIS, CLUBBING, LYMPHADENOPATHY CVS : S1S2 +VE, NO MURMURS
RS: BAE+VE, NVBS, NO ADDED SOUNDS P/A - SOFT, NON TENDER
CNS : E1V1M3 REFLEXES:- RT LT BICEPS :- 3+ 3+
TRICEPS :- 3+ 3+
KNEES :- 2+ 3+
ANKLE :- 2+ 2+
SUPINATOR:- 3+ 3+
PLANTAR EXTENSOR EXTENSOR
COURSE IN HOSPITAL-
A 62 YR OLD MALE BROUGHT TO CASUALITY IN UNCONSCIOUS STATE SINCE 1 HOUR
.PATIENT WAS THROUGHLY EXAMINED AND RELEVENT INVESTIGATIONS WERE DONE, PATIENT WAS DIAGNOSED AS GTCS SECONDARY TO HYPOGLYCEMIA ;ALTERED SENSORIUM(RESOLVING) SECONDARY GTCS-NEUROGLYCOPENIA ;K/C/O T2DM SINCE 21/2 YEARS; K/C/O HTN SINCE 5 YEARS ;K/C/O CVA RIGHT HEMIPARESIS 3 YEARS AGO ;IRON DEFECIENCY ANEMIA SECONDARY TO UPPER GI BLOOD LOSS;NUTRITIONAL;B12 DEFICENCY. DURING THE COURSE PATIENT WAS TREATED CONSERVATIVELY WITH ANTI CONVULSANTS,ANTIBIOTICSANTI HYPERTENSIVESANTI PYRETICS,MULTIVITAMINS, PPIs,25 D INFUSTION FOR 2 DAYS TO MAINTAIN GRBS 120 TO 160 MG/DL AND OTHER SUPPORTIVE TREATMENT WAS GIVEN .DURING THE STAY IN HOSPITAL PATIENT IMPROVED CLINICALLY AND HE IS BEING DISCHARGED IN A HAEMODYNAMICALLY STABLE CONDITION
Investigation
ABG 25-09-2024 09:08:PM PH7.37PCO218.3PO293.5HCO310.5 St.HCO314.2BEB-13.1BEecf- 13.8TCO222.2O2 Sat96.6O2 Count12.7HBsAg-RAPID25-09-2024 10:16:PM Negative Anti HCV Antibodies - RAPID25-09-2024 10:16:PM Non Reactive RFT 25-09-2024 10:16:PM UREA20 mg/dl50-
17 mg/dlCREATININE1.1 mg/dl1.3-0.8 mg/dl URIC ACID4.9 mmol/L7.2-3.5 mmol/LCALCIUM9.5 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.3 mg/dl4.5-2.5 mg/dlSODIUM136 mmol/L145-136 mmol/LPOTASSIUM4.1 mmol/L.5.1-3.5 mmol/L.CHLORIDE105 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 25-09-2024 10:16:PM Total Bilurubin0.78 mg/dl1-0 mg/dl Direct Bilurubin0.17 mg/dl0.2-0.0 mg/dl SGOT(AST)24 IU/L35-0 IU/LSGPT(ALT)11 IU/L45-0 IU/LALKALINE PHOSPHATASE89 IU/L119-56 IU/LTOTAL PROTEINS5.9 gm/dl8.3-6.4 gm/dlALBUMIN3.67 gm/dl4.6-3.2 gm/dl A/G RATIO1.65STOOL FOR OCCULT BLOOD27-09-2024
HEMOGRAM 25/09/24
HAEMOGLOBIN-9.9 gm/dl TOTAL COUNT-11200 cells/cummNEUTROPHILS-90%LYMPHOCYTES- 05%EOSINOPHILS-02%MONOCYTES-03%BASOPHILS-00%PCV-28.6 vol %M C V-57 fl M C H-
19.7 pg M C H C-34.6%RBC COUNT-5 millions/cumm PLATELET COUNT-3.1 lakhs/cu.mm SMEAR- Microcytic hypochromic WITH NEUTROPHILIC LEUKOCYTOSIS
HBA1C DONE ON 25/09/24:6.5% FBS DONE ON 26/09/24:117 MG/DL PLBS : 196 MG/DL
HEMOGRAM 27/09/24
HAEMOGLOBIN-7.8 gm/dl TOTAL COUNT-5900 cells/cummNEUTROPHILS-68%LYMPHOCYTES- 24%EOSINOPHILS-00%MONOCYTES-08%BASOPHILS-00%PCV-23.1 vol %M C V-58.2flM C H-
19.7 pg M C H C-33.8%RBC COUNT-3.9 millions/cumm PLATELET COUNT-2.3 lakhs/cu.mm SMEAR- Microcytic hypochromic
BGT DONE ON 28/09/24: B POSITIVE
STOOL FOR OCCULT BLOOD DONE ON 28/09/24: NEGATIVE
HEMOGRAM 28/09/24
HAEMOGLOBIN-7.6 gm/dl TOTAL COUNT-4500 cells/cummNEUTROPHILS-70%LYMPHOCYTES- 20%EOSINOPHILS-02%MONOCYTES-08%BASOPHILS-00%PCV-22.2 vol %M C V-57.7flM C H-
19.7 pg M C H C-34.2%RBC COUNT-3.8 millions/cumm PLATELET COUNT-2.1 lakhs/cu.mm SMEAR- Microcytic hypochromic
MDCT SCAN BRAIN-PLAIN DONE ON 25/09/24:-
IMPRESSION-CHRONIC INFARCTS IN RIGHT STRIATOCAPSULAR REGION AND LEFT THALAMUS
CHRONIC SMALL VESSEL ISCHEMIA
2D ECHO DONE ON 26/09/24:
EF-65%
NO RWMA;CONCENTRIC LVH GOOD LV SYSTOLIC FUNCTIONS
GRADE I DIASTOLIC DYSFUNCTIONS IVC SIZE (0.8CMS) COLLAPSING HEMOGRAM 29/09/24
HAEMOGLOBIN-7.3 gm/d lTOTAL COUNT-4100 cells/cummNEUTROPHILS-60%LYMPHOCYTES- 28%EOSINOPHILS-04%MONOCYTES-08%BASOPHILS-00%PCV-21.8 vol %M C V-58.5flM C H-
19.7 pg M C H C-33.7%RBC COUNT-3.73 millions/cumm PLATELET COUNT-2.28
lakhs/cu.mm SMEAR-Microcytic hypochromic
Treatment Given(Enter only Generic Name)
IVF NS WITH OPTINEURON@30ML/HR INJ.25% D INFUSION @5ML/HR INJ.LEVIPIL 500MG IV/BD
INJ.SODIUM VALPROATE 500MG IV/BD INJ.PIPTAZ 4.5ML/IV/QID X5 DAYS INJ.CLINDAMYCIN 600MG IV/TID X5 DAYS INJ.PAN 40MG IV/OD
INJ.NEOMOL 1GM/IV/SOS TAB.PCM 650MG RT/SOS TAB.STROCIT PLUS RT/BD
INJ.THIAMINE 200MG IN 100ML NS/IV/BD TAB.TELMA 20MG RT/OD
NEB WITH IPRAVENT 8TH HOURLY BUDECORT 12TH HOURLY
RT FEEDS 200ML MILK WITH PROTEIN POWDER 100ML WATER 2ND HOURLY
PHYSIOTHERAPHY TO RT UPPER AND LOWER LIMB
Advice at Discharge
TAB.LEVIPIL 500MG PO/BD TO BE CONTINUED
TAB.SODIUM VALPROATE 200MG PO/BD TO BE CONTINUED TAB.TELMA 40MG PO/OD AT 8AM TO BE CONTINUED TAB.STROCIT PLUS PO/BD TO BE CONTINUED
TAB.PAN-D 40MG PO/OD AT 7AM BBF X5 DAYS TAB REJUNEX CD3 PO OD X-1-X CONTINUE TAB ECOSPRIN AV 75/10 PO H/S
TAB LIVOGEN 150 MG PO OD 3 MONTHS TAB METFORMIN 500MG PO OD CONTINUE
TAB ULTRACET 1/2 TAB PO QID FOR 1 WEEK F/B SOS PHYSIOTHERAPY TO RT UL AND LL
FREQUENT ORAL FEEDS
Follow Up
REVIEW TO GM OPD AFTER 1 WEEK OR SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date Date:30/9/24 Ward:ICU
Unit:III
No comments:
Post a Comment