My experiences with general cellular and neural cellular pathology in a case based blended learning ecosystem's CBBLE "

 CASE OF 43 YEAR OLD MALE WITH SEIZURES

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.

AFEEFA FARZANA ,7th SEMESTER

Roll no:09

A 43 year old male patient was brought to the casuality on 18 october 2021 at 8:20 pm with 

Chief complaints of  fever and  sudden onset of involuntary movements of right  upper limb and right lower limb with frothing present and loss of consciousness 3 times lasting for 5 min.

HISTORY OF PRESENT ILLNESS [HOPI]:

Patient was apparently asymptomatic till 1 day ago .

Then he developed fever which was low grade and decreased on medication.

At 3:00 pm on 17 october 2021 , after he finished having lunch he suddenly developed one episode of Rt sided UL and LL involuntary movements with loss of consciousness for 10 mins, regained spontaneously and he did not talk after that.

After that he had 2 more episodes, each lasting for 2-3 mins, with one episode of vomiting.

He was treated outside with  inj Levipil 2g IV/ stat, catheterised and was referred here

PAST HISTORY:

He was born out of a non -consanguinous marriage. 

He had weakness in the fingers of right limb since childhood and was diagnosed with poliomyelitis at age 5 yrs  studied upto 6th standard and stopped school due to decreased attention and Memory impairment , walked with support and he used to carry out his daily activities with his left hand. 

He was given the job of taking care of cattle, till his father expired around 5 yrs back

5 years ago he had angry burst out and used to beat his family members . 

He was taken to yerragadda hospital where they prescribed him antipsychotics. Tab. Risperidone 2mg twice daily and Tab. Trihexiphenidryl 2mg once daily. Since then he is on antipsychotics and he had no episodes of anger burst out.

he is not a known case of DM,HTN,TB,asthma

no surgical history

PERSONAL HISTORY :

Diet : Mixed

Appetite : Normal

Sleep : Disturbed sleep before taking antipsychotics

Bowel and bladder habits : Regular

Addictions : Alcohol occasionally

Allergies : No drug and food allergies.

FAMILY HISTORY : 

No history of seizures in the family. 

No history of psychiatric problems in the family. 

GENERAL EXAMINATION:

Patient was not conscious ,incoherent, moderately build and moderately nourished

Pallor:  Absent

Icterus: Absent

Clubbing; Absent

Cyanosis; Absent

Lymphedenopathy: Absent

Edema; Absent

VITALS:

 on admission

Temperature- febrile

BP- 140/90 mm of hg

Pulse- 83 bpm

Respiratory Rate- 18

Oxygen saturation- 98% on room air

SYSTEMIC EXAMINATION:

CVS- S1 S2 +. No murmurs 

RS- NVBS. No crepts 

ABDOMEN- soft ,not tender, no palpable masses

CNS-

Drowsy but arousable

Speech- no response 

GCS- E2 V2 M5

Higher mental functions - cannot be elicited

Motor examination : 

                                RIGHT                      LEFT            

TONE         

 Upper limb          hypotonia                hypotonia     

 Lower limb          hypotonia                hypotonia

POWER                right                           left

 Upper  limb           0/5                          0/5

 Lower limb              0/5                         0/5

REFLEXES                right                     left

  Biceps                    -                            -

  Triceps                      -                               -

 Supinator                 -                               -

  Knee                         -                             -

Ankle                         -                              -

Plantar                       -                               - 

Gait cannot be examined. 

Sensory system cannot be examined. 

INVESTIGATIONS

                                                                      ECG : 

            

         

MRI BRAIN :

      MRI was done on 18th and 19th. After MRI patient had episode of vomiting. 

                                                         PSYCHIATRIC REFERAL : 

       

  

       

      

DIAGNOSIS :

Right side Focal seizures with secondary generalisation .

secondary to bilateral acute infarct in frontal with hemorrhagic transformation with history of psychosis and with history of right sided poliomyelitis

TREATMENT :

Ryles catheterisation

Inj lorezepam 2 cc/IV/ sos 

Inj mannitol 100 ml IV/TID

W/H Antipsychotics 

RT feeds- 50 ml milk 2nd hourly.

Day 2:

Inj mannitol 100 ml / IV/ TID

Inj Levipil 1 gm/ IV/ BD

Inj Lorazepam 2 cc/ IV / SOS 

RT feeds- 50 ml water 2nd hourly 

                100 ml milk 4th hourly 

Inj Monocef 1g IV/ BD

inj Enoxaparin 40 mg every 12th hourly

Day 3

 Pt was having constant fever spikes (100-101 F) since yesterday night and GCS -3/15 .

No response to deep painful stimulus. pulse rate intially was 52-58 bpm (bradycardia) for sometime. 

Later pt had tachycardia with pulse rate of 160-170 Bpm.(sinus tachy) .BP -160/100 mmhg

- INJ PCM 1gm was given twice and tepid sponging ,ice packs were placed. Heart rate decreased to 150 bpm.

At around 4:00 am , pt saturations started falling and spo2 -46% on RA.

Central pulse was present. But there was no spontaneous breathing .

So immediately ambu was done with high flow oxygen. Oral suctioning was done .

After adequate pre-oxygenation , pt was Intubated with 7 mm ET tube and connected to mechanical ventilator .

ACMV VC MODE : RR-14 /min ; FIO2- 100% ; 

VT- 480 ml ; peep-5 cm of h20 .

Post intubation vitals : BP- 120/70 mmHg - on NA -6ml/hr

PR- 116 bpm ; regular .

SPO2-.   98%        ; RR- 14

CVS -S1S2 PRESENT

RS- BAE present . b/l coarse crepts present.

post intubation ABG : 

ABG :

 pH - 7.18

Pco2- 59

Po2- 51

SO2- 73.8 %

Hco3- 18.3

POST INTUBATION X ray