60 YEARS OLD MALE WITH SEIZURES

 - August 26, 2022

 MEDICAL CASE

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

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


CASE DISCUSSION:

A 60year old male came with complaints of 

Involuntary movement of B/L upper limbs and lower limbs while driving at late night.


HOPI:

Patient was apparently asymptomatic few hours back and then suddenly developed involuntary movements of B/L upper limbs and lower limbs which lasted for 1hr and came to hospital in an unconscious state and gained consciousness after 2 hrs, but was in a state of confusion until morning 6am.

PAST HISTORY:

K/C/O DM since 10yrs

K/C/O HTN since 8yrs

PERSONAL HISTORY:

He is Married and Bus driver by occupation.
He consumes 
  • Mixed diet 
  • sleep is adequate 
  • Appetite normal
  • bowel and bladder movements are regular
  • He used to Consume Alcohol occasionally.
FAMILY HISTORY: no similar complaints in the family.

GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative and well oriented to time place 
and person, 

Moderately built and moderately nourished.

VITALS:

BP: 140/90mmhg
PR: 108
RR: 26
Temp: 99.5f
GRBS: 225mg/dl - 8am
Spo2: 97%

SYSTEMIC EXAMINATION:

RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS: pt conscious, coherent
HMF-intact
Reflexes-  R        L
B                ++       ++
T                ++       ++
S                ++        ++
K                ++        ++
A                ++        ++

PROVISIONAL DIAGNOSIS: Seizures under evaluation 

INVESTIGATIONS:






TREATMENT:
1. IV fluids 2 NS 2 RL @75ml/hr
2. Inj.levipil 1gm/iv/stat f/b inj.levipil 500mg/iv/bd
3. Inj. Pan 40mg/iv/OD/BBF
4. Tab.Dolo 650mg/PO/SOS
5. Inj.Human actrapid insulin SC/TID
6. GRBS charting 6th hrly
7. Tab. Prolomet-XL 50 mg/PO/OD
8. Inj. Lorazepam 2mg/iv/SOS

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