Monday, April 22, 2024

70M with Seizures,CVA and uncontrolled sugars,tracheostomised

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

CASE HISTORY:-

Chief complaints:-

H/o involuntary movements of left upper and lower limbs followed by unconsciousness 15 days ago.


Pt was born and brought up in nerada.He lead a healthy childhood living along with his family doing agriculture.He was illiterate,started farming at around 15 years of age and at 17 yrs of age started smoking due to peer pressure.At 25 years of age he got married to his wife and had 3 children .He had no health issues.20 years ago his middle child met with a Road traffic accident after that incident to allievate emotional distrubance he started consuming alcohol since then he consumes around 90 to 180ml of alcohol twice or thrice a week.He remained asymptomatic until 3 years ago then he had h/o generalised weakness and fever for which he went to hospital and diagnosed to have diabetes aa nd started on medication but due to financial reasons he used them irregularly and 1 and 1/2 yr ago one day he had weakness of right upper and lower limbs for which he was taken to nearby hospital there they diagnosed him of having CVA(right hemiparesis).He used medication and within 2 months his condition got improved and began to walk and do his daily activities.He discontinued medication after that.

15 days ago on his visit to in laws home he binged on alcohol for 3 days in sequence,decreased food intake and had an episode of involuntary movements of left upper and lower limbs followed by unconsciousness.They took him to hospital where he was found to have hypoglycemia.2 days later he got intubated i/v/o ?status epilepticus and later tracheostomised 3 days ago.

They brought the patient to casuality tracheostomised 

Past history in brief:-KNOWN CASE OF CVA SINCE 1 and 1/2YEAR, USING MEDICATION.

KNOWN CASE OF TYPE 2 DM SINCE 3 YEARS, ON IRREGULAR MEDICATION

NOT A K/C/O HTN, CAD, BRONCHIAL ASTHMA, THYROID DISORDER, TB, EPILEPSY

Personal history:-

MIXED DIET

APETTITE NORMAL

REGULAR BOWEL AND BLADDER

KNOWN ALCOHOLIC SINCE 20 YEAR

KNOWN SMOKER SINCE 15 YRS OF AGE

NO SLEEP DISTURBANCES.

FAMILY HISTORY:-NOT SIGNIFICANT

Vitals:-

PR:-98bpm

Bp:-130/80mm hg

Rr:-24cpm

Spo2:-98%

Fio2- 30,%

General examination:-PATIENTS IS ON MECHANICAL VENTILATOR.

MODERATLY BUILT AND NOURISHED 

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPTHY, 

EDEMA OF RIGHT UPPER LIMB SINCE 4 DAYS


Rs:-BLAE,Crepts+ in rt MA,LMA

Cvs:-S1S2 +,No murmurs

CNS:-

Pt is on drowsy but arousablestate

GCS:-E4VTM5

Tone rt  lt

UL ↓.       ↑

LL ↓.       ↑

Power couldnt be elicited

Reflexes

      B.    T.   S.  K.   A.  P 

Rt.  2+. -     -      -     -   flexion

Lt.   2+. 2+. -   +.    -   flexion

Pupils- b/l normal size and normal light reflex

Corneal and conjunctival reflex-present b/l

Doll's eye reflex absent

No neck stiffness 

Jaw jerk absent

Per abdomen:-soft,NT

Grbs:-133mg/dl



Investigations:-

Hemogram


Rft


Abg



Et tube c/s

blood c/s

tracheostomy c/s

Serial hemogram reports

serial RFT
LFt
ABGCUEFINAL DIAGNOSIS
RECURRENT CVA WITH ( PONTINE INFARCT) WITH ISCHEMIC SEIZURES  WITH SEPSIS; NON OLIGURIC AKI (RESOLVED) WITH TYPE I RESPIRATORY FAILURE ? HOSPITAL ACQUIRED PNEUMONIA; GRADE II BED SORES @ GLUTEAL REGION; K/C/O CVA SINCE 1 AND ½ YEARS; K/C/O TYPE II DM SINCE 3 YEARS, S/P TRACHEOSTOMY DAY-12; DENOVO HTN+ , POST INTUBATION DAY20

TREATMENT GIVEN:-
RT FEEDS
IV FLUIDS 2 PINT NS @ 75 ML/HR
INJ. PIPTAZ 2.25gm IV QID FOR 7DAYS
INJ PANTOP 2.25 GM 40 mg IV/OD
INJ. LEVIPIL 1 G IV/BD
INJ. GLYCOPYRROLATE 2 ML IV/SOS
INJ. HAI SC/ TID BEFORE MEAL 6U-6U-4U
INJ. NEOMOL 1G IV/ SOS (IF TEMP> 101 F)
INJ. OPTINEURON 1 AMP IN 100 ML NS
TAB. CLOPITAB 75 MG PO/HS RT/HS
TAB. STROCIT PLUS 800/500 MG RT/BD
TAB. CINOD 10 MG RT/ OD
 TAB. MET-XL 12.5 G RT/OD
TAB THIAMINE 200 MG IN 100 ML NS IV/BD
TAB. LIBRIUM 25 MG RT/TID
OINT. MEGAHEAL FOR LOCAL APPLICATIN OVER BEDSORE.
GRBS 7 POINTS PROFILE
AIR BED
POSITION CHANGE 2nd HOURLY
DAILY BEDSORE DRESSING WITH NEOSPORIN POWDER
PHYSIOTHERAPY OF ALL LIMBS
WATCH FOR SEIZURE ACTIVITY
LIMB ELEVATION