General medicine case presentation 7

October 28, 2021

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75 year old female Came to casualty with chief complaint of involuntary movements since yesterday night .

Urinary incontinance +

Uprolling of eye balls , no tongue bite

Aphasia ( resolved)

Patient was apprantly asymptomatic 3 years ago then she had h/o CVA with monoplegia and on regular medication.

H/o HTN since 3 years and on tab amlodipine 5mg , atenolol 50 mg . H/o trauma to right lower leg associated with swelling and fever was diagnosed as cellulitis and she neglected resulting in flare up of cellulitus for which she was admitted in our hospital twice .

H/o Epilepsy 6 mon back not on any medication .

K/C/O Dm type 2 since 6 months and on tablet METFORMIN 500 MG, GLEMIPERIDE 1 MG .

HISTORY OF PRESENT ILLNESS

Patient while doing her usual household activites at around 9 - 9:30 after having dinner while she went to bed and after some time her husband heard some noises and

On waking up patient was having involuntary movements with stiffening and movement of neck to right side which lasted for about 15 min with urinary incontinence twice and was taken to local doctor gave symptomatic treatment . Husband also gave h/o aphasia and Post ictal confusion after wakeup .

PAST HISTORY

DM since 6 mon and on medication TAB.METFORMIN 500 MG , GLEMIPERIDE 1MG.

HTN since 3 years and on medication TAB. AMLODIPINE 5MG , ATENOLOL 50 MG.

PERSONAL HISTORY

Diet : Mixed

Appetite : Normal

Sleep : Adequate

Bowels : constipation

Micturition : Normal

No addictions

Drug history : non allergic for any known drugs.

Family history :No significant family history

GENERAL EXAMINATION:

Patient was conscious, coherent, cooperative NO pallor , icterus , cyanosis, clubbing , lymphadenoapthy

VITALS

BP : 90/60 MM HG

PR : 72 / MIN

RR : 18 / MIN

SPO 2 : 98% ON RA

GRBS : 188 MG %

SYSTEMIC examination

CARDIOVASCULAR SYSTEM

Inspection:

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line

Ausculation:

S1 ,S2 Heard

RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breath sounds - heard

No added sounds

PER ABDOMEN

Abdomen is soft and non tender

Bowel sounds heard

No palpable mass or free fluid

CNS :

GCS - 15/15

HMF - INTACT

SPEECH - SLURRED

SENSORY SYSTEM - INTACT

Face deviation towards left side

MOTOR SYSTEM

R L

TONE UL NORMAL NORMAL

LL NORMAL NORMAL

POWER UL 5/5 5/5

LL 5/5 5/5

REFLEXES

B T S K A

R 2+ 2+ 2+ 2+ -

L - 2+ - 2+ -

PROVISNAL DIAGNOSIS

SEIZURES UNDER EVALUATION

K/C/O CVA SINCE 3 YEARS

K/C/O DM TYPE 2 SINCE 6 MON

K/C/O HTN SINCE 3 YEARS

INVESTIGATIONS

Treatment plan:

- IVF 1 unit NS WITH 1 AMP OF OPTINEURON.@ 75 ML /HR

- INJ . LEVIPIL 500MG IV BD

- INJ PAN 40 MG IV OD BBF

- INJ NEOMAL IF TEMP > 101 F

- TAB. DOLO 650 MG PO SOS

- TAB . ECOSPRIN GOLD

- TAB. GLIMI M1 PO OD

- INJ HUMAN ACTRAPID INSULIN S/C

25/10/21

ICU patient

A 75 year old patient with h/o seizures.

S: Patient is feeling symptomatically better. No episode of seizures again after admission. No other complaints.

O: Patient is conscious, coherent,co operative No pallor, icterus, cyanosis, lymphadenopathy, pedel edema.

VITALS:

BP: 110/70 mmhg

PR: 78 bpm

RR: 20 cpm

Temp: afebrile to touch.

CVS: S1 AND S2 HEARD.

RS: BAE +, NVBS.

P/A: soft and non-tender.

CNS:

Patient is conscious, coherent, cooperative and is well oriented to time, place and person.

Speech is slightly slurred. Comprehension present.

Cranial nerves: intact.

Motor system :

UL. LL

- Power: R 5/5 5/5

L 5/5. 5/5

- Tone: R n n

L. n n

- Reflexes: B T S K A P

R. + + - + - flexor

L + + - + - flexor

A: Seizures under evaluation.

K/C/O old CVA in left fronto temporal region.

Old infract in right putamen

K/C/O T2 DM since 6 months.

K/C/O HTN since 3 years.

Plan of treatment:

1) IVF ( NS, RL) @ 75ML.

2) Inj. Levil 500mg iv bd.

3) Inj. PAN 40MG iv od.

4) Inj. HAI S/C premeal TID.

5) Inj. Lorazepam 2cc iv sos.

6) Inj. NEOMOL 1gm iv sos.

7) Tab. ECOSPRIN GOLD.

8) Tab. Dolo 650mg po sos.

26/10/21

AMC patient