GENERALISED TONIC CLONIC SEIZURES 2° CVA

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 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.


Patient and his/her attenders have been informed and their consent has been taken.

 


55Y/ F  Came with involuntary movements of both upper and lower limb since 30 minutes. 

HOPI

Patient was apparently asymptomatic 30 minutes back then developed involuntary movements of both upper and lower limbs, sudden in onset, continuous. Associated with upward rolling of eyeballs, involuntary micturition, froth from mouth, 1episode of fever.  

Associated with deviation of angle of mouth towards left with tongue bite. 

No history of involuntary defecation. 

No history of head injury, vomiting, loose stools. 

PAST HISTORY

Known case of epilepsy since 20 years and on medication Tab. Phenytoin 100mg PO OD. 

During Last Pregnancy approx 24 years back she had ?Pre-eclampsia

Not a known case of Diabetes, hypertension, asthma, CAD, CVA. 

FAMILY HISTORY

Not significant

PERSONAL HISTORY

 Diet - Mixed

Appetite - Normal

Sleep - Disturbed

Bowel and bladder movements -regular

No known allergies

No addictions

GENERAL EXAMINATION



Patient is conscious, uncooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.

Vitals-

 Temp: 102.1°F

PR- 128bpm    

RR- 28cpm

BP- 140/80 mmHg

Spo2 -94%at RA

Grbs- 222mg/dl


SYSTEMIC EXAMINATION

CVS-  S1  S2 heard, no murmurs, no thrills

RS - NVBS heard

P/A - Soft, non tender

CNS- E1V1M6

 Speech no response

Cranial nerves cannot be elicited

Sensory system cannot be elicited

Tone of both upper and lower limbs- normal

Power  cannot be elicited

REFLEXES- 

           B.   T.      S.     K.    A

R.       2+   2+    -    2+       -

L.        2+   2+   -     2+       -


INVESTIGATIONS




Hb- 13.1. Tlc- 11.900. Plt- 1.66

LFT:

TB- 0.83 DB- 0.17. AST/ALT - 18/10

ALP-122. TP- 7.4. Alb- 3.73

RFT

U-26. S.Cr- 0.7 Na+146  K+ 4.2 Cl- 98

Troponin I 20.3 pg/ml.

DIAGNOSIS

GENERALISED TONIC CLONIC SEIZURES 2° CVA

TREATMENT

IV Fluids 75ml/hour

Inj Lorazepam 2ml IV STAT

Inj Levitracetam 2gm IV STAY F/B 1gm IV BD

Inj Ceftriaxone 20ml IV BD

Inj Optinueron 1ampole in 100ml NS IV OD

Tab Atorvastatin PO OD

Tab Ecospirin  75 mg PO OD


SOAP DAY 2

S: No episode of seizure. 

Fever subsided

O : Patient is conscious, coherent, cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.

Vitals-

 Temp: 97.8°F

PR- 85bpm    

RR- 20cpm

BP- 120/80 mmHg

Spo2 -98%at RA

Grbs- 134mg/dl

CVS- S1 S2 heard, no murmurs, no thrills

RS - NVBS heard

P/A - Soft, non tender

CNS- E4V4M5

 Speech normal

Tone of both upper and lower limbs- normal

Power cannot be elicited

REFLEXES-     B. T. S. K. A  P

R.                    2+ 2+ -   2+ -   Extensor

L.                    2+ 2+ -    2+ -   Extensor

 A:  GENERALISED TONIC CLONIC SEIZURES 2° CVA

P : IV Fluids 75ml/hour

Inj Levicetram 14ml IV BD

Inj Ceftriaxone 20ml IV BD

Inj Optinueron 1ampole in 100ml NS IV OD

Tab Atorvastatin PO OD

Tab Ecospirin 75 mg PO OD

Inj Lorazepam 2ml IV SOS



SOAP DAY 3

S:  Post ictal confusion present.

No episode of seizure. 

No Fever spikes. 

O : Patient is conscious, coherent, cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.

Vitals-

 Temp: 97.8°F

PR- 78bpm    

RR- 18cpm

BP- 110/70 mmHg

Spo2 -98%at RA

Grbs- 134mg/dl

CVS- S1 S2 heard, no murmurs, no thrills

RS - NVBS heard

P/A - Soft, non tender

CNS- E4V4M5

 Speech normal

Tone of both upper and lower limbs- normal

Power of both upper and lower limbs-  5/5

REFLEXES- B. T. S. K. A P

R.                 2+ 2+ - 2+ - Flexion

L                   2+ 2+ - 2+ - Flexion

 A: GENERALISED TONIC CLONIC SEIZURES 2° CVA

P : IV Fluids 75ml/hour

Inj Levicetram 500mg IV BD

Inj Ceftriaxone 2gm IV BD

Inj Optinueron 1ampole in 100ml NS IV OD

Tab Atorvastatin 20mg PO OD

Tab Ecospirin 75 mg PO OD

Inj Lorazepam 2ml IV SOS


SOAP DAY 3

S:No episode of seizure. 

No Fever spikes. 

O : Patient is conscious, coherent, cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.

Vitals-

 Temp: 97.8°F

PR- 72bpm    

RR- 18cpm

BP- 110/80 mmHg

Spo2 -98%at RA

Grbs- 122mg/dl

CVS- S1 S2 heard, no murmurs, no thrills

RS - NVBS heard

P/A - Soft, non tender

CNS- E4V4M5

 Speech normal

Tone of both upper and lower limbs- normal

Power of both upper and lower limbs- 5/5

REFLEXES- B. T. S. K. A P

R. 2+ 2+ - 2+ - Flexion

L 2+ 2+ - 2+ - Flexion

 A: GENERALISED TONIC CLONIC SEIZURES 2° CVA

P : IV Fluids 75ml/hour

Tab Levicetram 500mg PO BD

Inj Ceftriaxone 2gm IV BD

Inj Optinueron 1ampole in 100ml NS IV OD

Tab Atorvastatin 20mg PO OD

Tab Ecospirin 75 mg PO OD

Inj Lorazepam 2ml IV SOS


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