A 30 yr 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.


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.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


Unit 1 admission 

Amc 3rd bed


A 30 year old male came to the OPD with the complaints of

Vomiting since 4 am yesterday

For 10 episodes

H/ o chronic alcoholic since 5-6 years more than180 ml / day

H/ O chronic smoker since 2 years

No pain abdomen

H/O sudden stoppage of consumption of  alcohol 20 days back for 4 days associated with 1 episode of seizure like activity with no history of trauma 

associated with facial puffiness 



on examination:  patient is c/c/c

congestion in both eyes 

Icterus  present 

black discoloration around eyes


Vitals : 

Afebrile

BP- 110/70

PR- 78bpm


CVS- s1,S2 heard

RS- BAE present ,NVBS

P/ A : soft , non tender

CNS: normal


Provisional diagnosis:

Alcohol withdrawal  seizure

Rt LL cellulitis

H/o head trauma


Investigations:

Hb-13.6

Tlc-6700

Plt-60,000



Lft

Tb-1.57

Db-0.48

Ast-70

Alt-115

Alp-165

Tp-6.7

Alb-3.8

A/g-1.35

Blood urea-15

S.crea-0.7


S.e

Na+--139

K+-4.1

Cl-92


On 14/09/21

Se

Na+ 137

K+ 3.6

Cl- 95


On 15/09/21

Hb- 14.2

Tlc- 5400

Plt- 60,000

Pcv- 38.6

Rbc- 4.46

Fbs- 86

Plbs- 107

Hba1c- 6.6


On 16/09/21

Serum electrolytes

Na+ 139 

K + 4 

Cl-  101


Chest x ray

 


Ecg





CT brain



Usg abdomen







X ray foot




Treatment given 
DAY 1
1) INJ THIAMINE 2 AMP IN 100 ml NS
2)INJ  OPTINEURON 1 AMP IN 100 ml NS
3) IVF
4)INJ PAN 40 mg IV / OD
5) INJ ZOFER 4 mg IV / BD
6)INJ LORAZEPAM 2 mg  IV/ SOS
7) INJ LEVIPIL 500 mg IV/ sos
8) MOXIFLOXACIN DROPS 4 times/ day
9) INJ AUGMENTIN  1.2 g IV / BD
10) E/D  LUBREX EYE DROPS 4 times / day

DAY 2 

 1)INJ THIAMINE 2 AMP IN 100 ml NS
2)INJ  OPTINEURON 1 AMP IN 100 ml NS
3) IVF
4)INJ PAN 40 mg IV / OD
5) INJ ZOFER 4 mg IV / BD
6)INJ LORAZEPAM 2 mg  IV/ SOS
7) INJ LEVIPIL 500 mg IV/ sos
8) MOXIFLOXACIN DROPS 4 times/ day
9) INJ AUGMENTIN  1.2 g IV / BD
10) E/D  LUBREX EYE DROPS 4 times / day

Day 3 

1) IVF
2) INJ PANTOP 40mg IV/OD
3)INJ AUGMENTIN 625mg IV/ BD
4) INJ METROGYL 500 mg IV/ TID
5) INJ THIAMINE 1 AMP IN 100 ML NS IV/ TID
6) INJ LEVIPIL 500 mg IV/ BD
7) T. CHYMORAL FORTE 500 mg PO/ TID
8) T. ULTRACET PO/SOS
9) T. LIBRIUM 25 mg
10) T. DIVALPROATE SODIUM 500 mg PO/OD
11) T. BACFEN  XL 20 mg PO/ OD
12 ) NICOTEX GUMS 2mg TID/ SOS
13) INJ LORAZEPAM 1 AMP 4 mgIM/ SOS


Day 4
1) IVF
2) INJ PANTOP 40mg IV/OD
3)INJ AUGMENTIN 625mg IV/ BD
4) INJ METROGYL 500 mg IV/ TID
5) INJ THIAMINE 1 AMP IN 100 ML NS IV/ TID
6) INJ LEVIPIL 500 mg IV/ BD
7) T. CHYMORAL FORTE 500 mg PO/ TID
8) T. ULTRACET PO/SOS
9) T. LIBRIUM 25 mg
10) T. DIVALPROATE SODIUM 500 mg PO/OD
11) T. BACFEN  XL 20 mg PO/ OD
12 ) NICOTEX GUMS 2mg TID/ SOS
13) INJ LORAZEPAM 1 AMP 4 mgIM/ SOS




 







Comments

Post a Comment

Popular posts from this blog

A 42 year female with multiple health issues.

-
G sai tejaswini Roll no 61  I have been given this case to solve in attempt  and 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  treatment plan. Entire real patient clinical problems in this link herehttps://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1 Following is my analysis of the patient problem. Problems are Swelling of face and abdomen  Sleep disturbances Oliguria Rashes Headaches(migraine with aura) Fatigue Swelling of face and abdomen: she was diagnosed as G6PD deficiency  which cauese hemolytic anemia ie hemolysis of rbc  may cause right heart failure which may be the cause of shortness of breath and swelling .  Swelling of face may be caused due renal failure (oxidative stress due G6PD deficiency). This deficiency causes decreased generation ofNADPH and ATP which causes
Read more

Analysis on 45year old female patient with anasarca

-
Image
 G SAI TEJASWINI ROLL NO 61 I have been given this case in an attempt to solve in attempt to understand the patient's clinical data analysis to develop my competency in reading and comprehending including history, clinical findings, examination, investigations, and plan of treatment  The complete details of the patient's history  https://alekyatummala.blogspot.com/2020/09/45-yr-female-with-anasarca.html?m=1  are given this case The main complaints of the patient are - 1. Pedal edema pitting type 2. Generalized edema 3. Shortness of breath at rest (NYHA grade 4) 4. Chest pain on the right side 5. Anuria  Causes of generalized edema : 1.Heart failure  2.cirrhosis of liver 3.kidney disease 4.hypoalbuminemia 5. Drug-induced edema 6. nutritional origin what is the anatomical and etiological diagnosis of the patient : anatomical diagnosis- kidney injury etiological diagnosis-nephropathy due to diabetes, hypertension what are the reasons for : azotemia  is a medical condition characte
Read more

Case of 18years old boy with weakness of lower limbs

-
G sai tejaswini  Roll no 61 Ihave be given this case to solve ina an attempt and to understand the topic of paitient 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. Entire real patient clinical problem  inthis link herehttps://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1 A18 year old male patient came with complaints of  difficulty in walking , bilateral lowerlimb weakness, pain in calf muscles since 1month. Analysis of the case: By above mentioned data inthe link. The features may be of lower motor lesions. LOWER MOTOR LESIONS:at the level of -anterior horn cells -nerve roots -peripheral nerves -neuromuscular junction -muscle ANTERIOR HORN CELLS :may be effected by polio,   spinal muscular atrophy( mainly along with areflexia and weakness, hypotonia, may involve respiratory muscles genetic disorder which can be
Read more