A 65 yr old male with seizures

Final exam long case



65 year old male patient with Seizures

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's 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 inputs on the comment"
Date of admission:18/01/2023

Chief complaint : A 65 yr old male was brought to the casuality with c/o invoulantary  movement of left upper and lower limbs associated with uprolling of eyeballs and biting of tongue
History of present illness: patient was apparently asymptomatic till 1pm on 18 /01/2023 developed  fever and at 4pm developed  seizures  
Involuntary micturition and defecation
H/o Weakness of left upper limb and left lower limb 
History of past illness:
History of similar complaints in the past 
H/o seizures 1 1/2 year back with high grbs at the time of hospitalisation  in 2021
   2021 
 Fasting blood sugar:106 mg/dl

Post lunch blood sugar : 234mg/dl
H/o seizures 3 times 
1st seizure on 11/07/2021
2 nd on 13/03/2022
3rd on 18/04/2022
4th on 18/01/2023

H/o hypertension 3 years back
H/o Diabetes 6 years back
H/o cva 2 years back
H/0 CAD
Personal History:
Occupation:farmer
Married
Apetite:normal
Diet:mixed
Micturation:involuntary 
Sleep:adequate 
Bowel movements:normal
Addictions: no Addictions 
No known case of allergy
Family History:
No relevant history of diabetes,asthma,heart disease, tuberculosis 
H/o hypertension 

General Examination:
Patient is conscious,not coherent and not cooperative 
No pallor,icterus,clubbing,cyanosis,lymphadenopathy,edema
Vitals
Temperature:102.7
Pulse rate:120bpm
Respiratory rate:20 cyclesper min
BP:136/100mm Hg
Grbs:201mg%
Systemic examination:
CVS:   No thrillls heard, S1S2 heard 
RESPIRATORY SYSTEM: position of trachea is central,No dyspnoea,No wheeze,vesicular breath sounds heard
ABDOMEN:non tender,no palpable mass,no palpable spleen & liver
CNS:
Patient is drowsy, speech is slurred
Neck stiffness is seen 
Kernings sign is negative
Cranial nerves 
1st olfactory
2nd optic
3rd occulonotor
4thtrochlear
5th trigeminal
6th abducen
7th facial nerve- 
8th vestibulococchler
9th glossopharyngeal.
10th vagus
11th spinal accessory
12th hypoglossal
All other  cn are normal
Motor system:
Bulk of the muscle: Normal

Tone: Right Upper limb. More
          Right lower limb : more
   Left upper limb : decreased
Left Lower limb: decreased 

Power:             left.            Right
Upper limb.  4/5.                5/5
Lower limb.   4/5.              5/5

Reflexes:  Biceps    triceps   supinator     
Right         +.               +.              +
Left        +++.          +++.              ++
            knee.   Ankle.     Plantar flexor
Right.   +.      -.             - 
Left     ++.        ++.         -
Cerebellar signs
No finger nose coordination
No knee heel coordination
Examination of oral cavity: Tongue bite is seen
Examination of head and neck : Neck stiffness seen
Provisional diagnosis:Focal seizures with secondary generalisation 
Investigations:
Xray
Hemogram
Complete urine examination
Random blood sugar
Renal function tests
Liver function tests
CT brain (13/03/22)
Chronic infarct in right parieto occipital region
ECG REPORT ON DAY OF SEIZURES:
ECG on the next day:
other findings:
 Chest x ray - no abnormalities 


MRI.   


Treatment:
Insulin iv
Tab.phenytoin 100 mg RT/BD 
               1-0-1
Tab sodium valproate 1000 mg  RT/BD
               1-0-1
Tab ecospirin and atorvastatin 75/10 mg RT/HS 
            0-0-1
Injection b complex 1 amp in 100 ml ns iv od
0-2pm -0
Tab telma 40 mg 
Iv monocef 1 gm iv 
Tab dolo 650 mg RT tid
RT feeds - water 2 nd hourly
                 - milk and protein powder 4 th hourly
    Syrup potassium chloride 15 ml
Grbs  monitoring every 2 nd hourly
Temperature monitoring second hourly



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