SUCHITHA KOLA 65

Greetings to one and all who are reading my blog.This is Suchitha Kola,Rno-65,a Third semester student.

"This is 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 patients clinical problems with collective current best evidence based inputs"

INTRODUCTION:

•A 40 year old male patient came to casualty with chief complaints of five episodes of seizures - focal (right side) with secondary generalisation associated with loc involuntary micturition since today morning for which he was taken to a local hospital and got treated symptomatically. 

•From there he was referred to one hospital for further treatment. Pt was brought to casuality in a state of altered sensorium . 

HISTORY OF PRESENT ILLNESS:

•H/o generalized weakness & body pains since one day.

•No history of fever/vomiting/headache/weakness of of UL/LL/deviation of mouth.

•No other complaints.

PAST HISTORY:

•Not a known case of DM/HTN/Asthma/Epilepsy/CAD

•Not a known case of TB

PERSONAL HISTORY:

•Daily wage labourer

•Consumes alcohol 180 ml/ day since 20 years.

• Cigeratte smoking 15 / day since 20 years .

GENERAL EXAMINATION:

 •No pallor /icterus /cyanosis / clubbing /lymphadenopathy /pedal edema.

•Temp: 100 F

•Pulse rate: 96 /min.

•Bp :90/50

•Spo2 at room air 99 %

•GRBS :131 mg% 

SYSTEMIC EXAMINATION:

CVS:

 •s1 s2 heard , no murmurs

Respiratory system : 

•BAE+ , normal vesicular breath sounds heard.

Abdomen : 

•soft , BS+

Central Nervous System : 

•Drowsy but arousable.

•Neck stiffness +

•Kernig's +

•Brudzinski -

•Glasgow scale : E3V4M5 

•Reflexes: DTR: Exaggerated

•plantars : Unelicitable

PROVISIONAL DIAGNOSIS:

• focal seizures with secondary generalisation

•Altered sensorium under evaluation.

•? Meningo encephalitis

•? Septic encephalopathy

•Plan: CSF analysis(which has been taken and can be seen in following blog)

INVESTIGATIONS:

•Hemogram:

•Hb- 12.9

•TC- 19,000

•Neutrophil- 80

•lymphocytes-13

•Esinophils- 2

•Monocytes- 5

•Basophils-0

•PCV- 38.1

•MCV-86.2

•MCHC-33.9

•RDW-CV-13

•RDW-SD-41.8

•RBC Count-4.42

•Platelet count- 4.3

•Clinical Urine Examination:

•Colour: pale yellow

•Appearence:hazy

•Reaction:acidic

•Sp.gravity-1.010

•Albumin:++

•Sugars:Nil

•Bile salts:Nil

•Bile pigments:Nil

•Pus cells:3-4

•Epithelial cells:2-3

•RBC-Nil

•Crystals:nil

•Amorphous deposits:Nil

•Random Blood Sugar(RBS):118

•Serum Electrolytes:

•Na+:138

•K+:3.6

•Cl-:101

•Liver Function Test:

•T.bilurubin- 0.78

•D.bilirubin- 0.18

•AST-42

•ALT-95

•ALP-355

•Total protein- 6.1

•ALB- 3.2

•A/G ratio-1.08

•ABG:

•pH: 7.476

•PCo2: 30.6

•PO2:86.5

CSF INVESTIGATION:

•After Lumbar puncture,CSF is happened to be clear

•Total Cell count:3

•DC:100% Lymphocytes

(As of my knowledge,0-5 cell count of CSF shows absence of meningitis,where in meningitis pts it exceeds 5)

•TREATMENT:

•IV Fluids :NS at 100ml/HR(continuous infusion)

•Injection CEFTRIAXIONE 1gm IV/BD

•Injection LEVIDIL 500mg BD/IV

•Injection LORAZ 2cc IV /SOS

•Injection THIAMINE 1amp M 100ml NS IV

•Injection OPTINEURON 1amp M 100ml NS IV

•BP/PR/Temp/SpO2 Monitoring

•Tablet DOLO 650mg T.D

•FINAL DIAGNOSIS:

• As this an ongoing case we are still on provisional diagnosis but not on a proper complete diagnosis.

---------THANK YOU------