Case 47 70 male with involuntary movements

Doa 28/8/24

Dod 2/9/24

Diagnosis

GTCS SECONDARY TO HYPOGLYCAEMIA ? UREMIA,ASPIRATION PNEUMONIA

AKI ON CKD

K/C/O EPILEPSY,CVD

K/C/O HTN,DM 11 - 3YEARS

POSTSEIZURE PALSY- TODDS PALSY

S/P 2 SESSION OF HD

ALCOHOL WITHDRAWAL

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O INVOLUNTARY MOVEMENTS B/L UPEER AND LOWER LIMBS SINCE AFTERNOON

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC TILL TODAY AFTERNOON THEN HE DEVELOPE

INVOLUNTARY MOVEMENTS IN B/L UPPER LIMBS AND LOWER LIMBS INSIDIOUS IN ONSET

,GRADUALLY PROGRESSIVE ASSOCIATED WITH DEVIATION OF MOUTH TO LEFT

TONGUE BITE - +

FROTHING FROM MOUTH - +

NO H/O FEVER ,CHEST PAIN , PALPITATIONS,BREATHLESNESS,ORTHOPNEA,PND

PAST HISTORY:

K/C/O DM TYPE 2 , HTN SINCE 2 YEARS - ON UNKOWN MEDIACTION

K/C/O EPILEPSY SINCE 3 YEARS ON TAB.LEVIPIL 500MG PO/OD

CVA- LEFT HEMIPARESIS

NO H/O CAD, ASTHMA

PERSONAL HISTORY

APPETITE - NORMAL

BOWELS - REGULAR

MICTURITION-NORMAL

AT TIME OF ADMISSION :

TEMP:97.6F

BP: 90/60 MM/HG

PR:160 BPM

RR:28 CPM

SPO2: 72%@RA TO 94% WITH 14LT O2

GRBS : 45 MG/DL TO 328 MG/DL

NO ICTERUS, PALLOR, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA

CVS : S1S2 +VE, NO MURMURS

RS: BAE+VE, NVBS, NO ADDED SOUNDS

P/A - SOFT

CNS :

PATIENT IS DROWSY BUT AROUSABLE

GCS - E4V2M4

REFLEXES:- RT LT

BICEPS :- - -

TRICEPS :- - -

KNEES :- +2 +2

ANKLE :- - -

SUPINATOR:- - -

PLANTAR FLEXION FLEXION

COURSE IN HOSPITAL:

70 YRS OLD MALE PATIENT K/C/ TYPE 2 DIABETES MELLITUS, HTN,SEIZURE DISORDER

SINCE 3YRS CVA (RESOLVED) 3YRS AGO CAME WITH A COMPLAINTS INVOLUNTARY

MOVEMENTS B/L UPEER AND LOWER LIMBS SINCE AFTERNOON AND THROWING ACTIVE

SEIZURES IN CASUALITY TERMINATED WITH BENZODIAZEPINE (INJ LORAZ). NECESSARY

INVESTIGATIONS WERE DONE. PATIENT INITIAL GRBS WAS 45MG/DL AND DIAGNOSED AS

SEIZURES SECONDARY TO HYOGLYCEMIA ? METABOLIC. NECESSARY INVESTIGATIONS

WERE DONE AND DIAGNOSED AS GTCS SECONDARY TO HYPOGLYCAEMIA ?ASPIRATION

PNEUMONIA ,REANL AKI , ALI , K/C/O EPILEPSY,CVD ,K/C/O HTN,DM 11 - 3YEARS,

POSTSEIZURE PALSY- TODDS PALSY S/P 1 SESSION OF HD DONE ON 30/8/24. MRI BRAIN

WAS DONE WHICH SHOWS CHRONIC INFRACT IN RIGHT OCCIPITAL LOBE WITH

ENCEPHALAMALACIC CHANGES AND DIFFUSE CEREBRAL ATROPHY. DURING THE STAY

PATIENT SENSORIUM WAS IMPROVED BUT URINE OUTPUT WAS DECRESED WITH

DERANGED RENAL PARAMETERS(AKI). HENCE PATIENT TAKEN FOR 2 SESSIONS OF

HEMODIALYSIS AND TREATED CONSERVATIVELY WITH RYLES FEEDS ANTI EPILEPTICS

ANTI COAGULANTS ANTI PLATELETS ANTIBIOTICS ANTACIDS ANTI DIURETICS ANTI

EMETICS AND PHYSIOTHERAPY FOR LEFT U/L LL OTHER SUPPORTIVE TREATMENT GIVEN.

AS PATIENT IS IMPROVING CLINICALLY AND I/V/O HIGH UREA CREATININE AND

DECREASED URINE OUTPUT PATIEN IS GETTING TRANSFERED TO DEPARTMENT OF

NEPHROLOGY FOR HEMODIALYSIS AND OTHER SUPPORTIVE TREATMENT.

Investigation

ABG 28-08-2024 06:10:PMPH 7.20PCO2 36.8PO2 128HCO3 13.8St.HCO3 14.4BEB -13.2BEecf -

12.6TCO2 29.1O2 Sat 97.2O2 Count 17.7

COMPLETE URINE EXAMINATION (CUE) 28-08-2024 07:55:PMCOLOUR Pale

yellowAPPEARANCE clearREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++++SUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 4-5EPITHELIAL CELLS 2-3RED BLOOD CELLS 10-

15CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilAnti HCV Antibodies -

RAPID 28-08-2024 07:55:PM Non Reactive

HBsAg-RAPID 28-08-2024 07:55:PM Negative

RFT 28-08-2024 07:55:PMUREA 35 mg/dl 50-17 mg/dlCREATININE 2.0 mg/dl 1.3-0.8 mg/dlURIC

ACID 12.0 mmol/L 7.2-3.5 mmol/LCALCIUM 9.2 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.0 mg/dl 4.5-

2.5 mg/dlSODIUM 142 mmol/L 145-136 mmol/LPOTASSIUM 3.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

103 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 28-08-2024 07:55:PMTotal Bilurubin 1.95 mg/dl 1-0 mg/dlDirect

Bilurubin 0.58 mg/dl 0.2-0.0 mg/dlSGOT(AST) 1001 IU/L 35-0 IU/LSGPT(ALT) 684 IU/L 45-0

IU/LALKALINE PHOSPHATASE 194 IU/L 119-56 IU/LTOTAL PROTEINS 7.6 gm/dl 8.3-6.4

gm/dlALBUMIN 4.7 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.64

RFT 29-08-2024 11:10:PMUREA 100 mg/dl 50-17 mg/dlCREATININE 4.3 mg/dl 1.3-0.8 mg/dlURIC

ACID 12.0 mmol/L 7.2-3.5 mmol/LCALCIUM 9.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 6.2 mg/dl 4.5-

2.5 mg/dlSODIUM 142 mmol/L 145-136 mmol/LPOTASSIUM 4.0 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

101 mmol/L 98-107 mmol/L

RFT 1-08-2024 11:10:PMUREA 65 mg/dl 50-17 mg/dlCREATININE 4.1 mg/dl 1.3-0.8 mg/dlURIC

ACID 4.0 mmol/L 7.2-3.5 mmol/LCALCIUM 7.2 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.7 mg/dl 4.5-

2.5 mg/dlSODIUM 142 mmol/L 145-136 mmol/LPOTASSIUM 3.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

104 mmol/L 98-107 mmol/L

RFT 2-09-2024 11:10:PMUREA 112 mg/dl 50-17 mg/dlCREATININE 5.8 mg/dl 1.3-0.8 mg/dlURIC

ACID 4.7 mmol/L 7.2-3.5 mmol/LCALCIUM 8.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 5.2 mg/dl 4.5-

2.5 mg/dlSODIUM 141 mmol/L 145-136 mmol/LPOTASSIUM 3.2 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

104 mmol/L 98-107 mmol/L

ABG 30-08-2024 09:28:AMPH 7.26PCO2 33.0PO2 68.6HCO3 14.3St.HCO3 15.4BEB -11.5BEecf -

11.4TCO2 29.9O2 Sat 90.1O2 Count 15.3POST LUNCH BLOOD SUGAR 30-08-2024 05:28:PM 109

mg/dl 140-0 mg/dl

ULTRASOUND DONE ON 30/08/24

IMPRESSION -

INCREASED ECHOGENICITY OF RIGHT KIDNEY

LEFT KIDNEY GRADE 1 RPD CHANGES

MRI BRAIN DONE ON28/08/24

IMORESSION:

CHRONIC INFRACT IN RIGHT OCCIPITAL LOBE WITH ENCEPHALAMALACIC CHANGES

DIFFUSE CEREBRAL ATROPHY.

2D ECHO DONE ON 29/08/24:

IMPRESSION

CONCENTRIC LVH (+): NO RWMA

TRIVIAL TR/AR/MR: NO PAH

MAC : SCLEROTIC AV :NO AS/MS

EF= 60% RUSP2 32MMHG

GOOD LV SYSTOLIC FUNCTION

GRADEI DIASTOLIC DYSFUNCTION

IVL SIXE (0.8CM)COLLAPSING

NO PE/LV CLOT

Treatment Given(Enter only Generic Name)

1.RT FEEDS 100ML WATER,2ND HOURLY 200ML MILK-4TH HOURLY

2IVF,NS,RL 40+30ML/HR/(URINE OUTPUT+30ML/HR)

3.INJ. OPTINEURON 1 AMP IN 100ML NS/IV/OD

4.INJPIPTAZ 2.25GM IV/QID FOR 6 DAYS

5.INJ. CLINDAMYCIN600MG IV/TID FOR 6 DAYS

6.INJ LEVIPIL 500MG IV/TID

7.INJ PAN 40MG PO/OD

8.INJ THAMINE 200MG IN 100ML NS IV/BD

9.TAB.ECOSPRIN 75 RT/H/S

10.TAB.ROSUVASTAT 10MG RT/H/S

11.INJ LASIX 40 MG RT/BD 8AM AND 3PM

12.TAB.STROCIT PLUS RT/BD

13.TAB.SAM (S-ADENOSYL L-METHIONINE ) 400MG RT/TID

14.TAB.SEVELAMER 400MG RT/BD

15.TAB.NEPHROSAVE (TAURINE +N-ACETYL CYSTEINE) RT/BD

16.TAB.ULTRACET RT/BD

17.TAB.MYORIL 300MG RT/BD

18.NEB BUDECORT - 12 HRLY

IPRAVENT - 6TH HRLY

Advice at Discharge

1. TAB LEVIPIL 5000MG RT/BD CONTINUE

2.TAB.ECOSPRIN 75 RT/H/S CONTINUE

3.TAB.ROSUVASTAT 10MG RT/H/S CONTINUE

4.TAB PAN 40 MG RT/OD X1WEEK

5. TAB BENFOTHIAMINE 200MG BD X1WEEK

6.TAB LASIX 40 MG RT/BD 8AM AND 3PM X1WEEK

7.TAB.STROCIT PLUS RT/BDX2WEEK

8.TAB.SAM (S-ADENOSYL L-METHIONINE ) 400MG RT/TID X1WEEK

9.TAB.SEVELAMER 400MG RT/BD X1WEEK

10.TAB.NEPHROSAVE (TAURINE +N-ACETYL CYSTEINE) RT/BD X1WEEK

11.TAB.ULTRACET RT/BD X 5 DAYS

12.TAB.MYORIL 300MG RT/BDX 5 DAYS

13. TAB UDILIV 300MG RT/BDX 5 DAYS

Follow up lost