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55 year old male who is a farmer came to casuality with alleged history of seizure activity on 28/2/22 for which he was admitted in a hospital where he was resuscitated and intubated after having cardiac arrest on day 2 (4 am) of his stay at the hospital.
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic 6 years back then he suffered with sudden onset seizure activity which lasted for 8- 10 minutes ON 28/2/2022 .
He had h/o involuntary movements of upper limb and lower limb with uprolling of eyes along with aura ,involuntary micturition and defecation, tongue bite, post ictal confusion.
He was rushed to a nearby hospital and was treated conservatively .During the stay in the hospital patient had cardiac arrest on day 2 of admission at 4 a.m. was intubated and put on mechanical ventilator and referred to us in view of of their affordability issues.
History of fever since 3 days.
PAST HISTORY:
k/c/o seizures since 6 years.
History of trauma to head 10 years back (fall from bike ) ,no chief complaints of LOC, headache, seizures giddiness.
H/o seizure attack 6 years back for which he was treated with levipril.
1 year back he had another seizure activity since then he was advised to take regular medication ( levipil) to avoid future seizure activity but the patient didn't take regular medication.
Not a known case of DM and HTN.
PERSONAL HISTORY:
Alcoholic since 15 years , tobacco smoking since 30 years
GENERAL EXAMINATION:
O/E : patient is on mechanical ventilator
FiO2 - 40%
PEEP- 5
VT - 420
GCS: E1 VT M2
Pallor - present
Icterus absent
Cyanosis - absent
Edema of feet - present
Lymphadenopathy - absent
Clubbing - absent
VITALS:
Temperature: 100 F
BP: 140/80mmhg
PR: 112 bpm
RR : 18CPM
SYSTEMIC EXAMINATION:
CNS:
Pupils - B/L NSRL
Reflexes:
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee 3+ 3+
Ankle - -
Plantar flexion flexion
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard
RESPIRATORY SYSTEM : BAE present
P/A : soft
INVESTIGATIONS:
5/3/22
BGT: B POSITIVE
6/3/22
SPOT URINE PROTEIN: 7
SPOT URINE CREATNINE: 74
RATIO: 0.09
PROVISIONAL DIAGNOSIS:
SEIZURE UNDER EVALUATION (? ALCOHOL WITHDRAWAL SEIZURE) ? HYPOXIC ENCEPHALOPATHY POST CPR STATUS DAY 5
TREATMENT:
HEAD AND ELEVATION UP TO 30%
INJ. MEROPENEM 1 G IV BD
INJ. LEVIPIL 500 MG IV BD
INJ MIDAZOLAM 10 MG IN 50 ML NS @ 30 ML/ hr INJ. MANNITOL 100 ML IV BD
INJ. PANTOP 40 MG IV OD
INJ. NEOMOL 100 ML IF TEMPERATURE > 101 F INJ THIAMINE 2 AMP IN ONE DNS IV BD
SOAP NOTES:
DAY 2(7/3/22)
S:- Fever spikes present
O: patient is on mechanical ventilator
PEEP- 5
FiO2 - 40%
VT - 400ml
VITALS:
temp- febrile
BP 140/80 mm hg
PR 130 bpm.
RR 18 cpm
spo2: 92% with Fio2 40%
CVS - S1, S2 heard ,muffled heart sounds
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils :B/L NSRL
REFLEXES : right left
Biceps. 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee - -
Ankle - -
Plantar mute mute
A:- Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 7 , mechanical ventilator day 6
Day 3:(8/3/22)
S:- no fever spikes
O- O/E : patient is on mechanical ventilator
PEEP- 5
FiO2 - 40%
VT - 400ml
Timp : 2.1
VITALS:
temp- afebrile
BP: 110/90mm hg
PR: 115 bpm.
RR: 16 cpm
spo2: 99% with Fio2 40%
GRBS: 168 mg/dl
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils :B/L NSRL
GCS: E1VTM2
Cough reflex present
corneal reflex present
conjunctival reflex present
REFLEXES : right left
Biceps 2+ -
Triceps 2+ 2+
Supinator 2+ 2+
Knee 3+ 3+
Ankle - -
Plantar mute mute
A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 8 , mechanical ventilator day 7
P: ENT opinion i/v/o tracheostomy
Day 4:(9/3/22)
S:- fever spikes present
O- O/E : patient is on mechanical ventilator
PEEP- 5
FiO2 - 40%
VT - 400ml
Timp : 2.1
VITALS:
temp- 100.9 F
BP: 120/90mm hg @ NORAD 6ml /hr
PR: 114 bpm.
RR: 16 cpm
spo2: 99% with Fio2 40%
GRBS: 129 mg/dl
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils :B/L NSRL
GCS: E1VTM1
Cough reflex present
corneal reflex present
conjunctival reflex present
REFLEXES : right left
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee 3+ 3+
Ankle - -
Plantar extensor extensor
A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 9 , mechanical ventilator day 8
S:- no fever spikes
O- O/E : patient is on mechanical ventilator
PEEP- 7
FiO2 - 40%
VT - 400ml
Timp : 2.6
VITALS:
temp- Afebrile
BP: 90/50mm hg @ NORAD 8ml /hr
PR: 109 bpm.
RR: 14 cpm
spo2: 99% with Fio2 40%
GRBS: 181 mg/dl
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils :B/L NSRL
GCS: E1VTM1
Cough reflex present
corneal reflex present
conjunctival reflex present
REFLEXES : right. left
Biceps 2+ 2+
Triceps . 2+ 2+
Supinator 2+ 2+
Knee 2+ 2+
Ankle - -
Plantar extensor extensor
A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 10, mechanical ventilator day 9
Day 6 (11/3/22):
S:- no fever spikes
O- O/E : patient is on mechanical ventilator
PEEP- 7
FiO2 - 40%
VT - 400ml
Timp : 1.9
VITALS:
temp- Afebrile
BP: 140/80mm hg @ NORAD 10ml /hr,vaso 2ml/hr
PR: 73 bpm.
RR: 14 cpm
spo2: 99% with Fio2 40%
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils :B/L sluggish reaction to light
GCS: E1VTM1
corneal reflex present
conjunctival reflex present
REFLEXES : right. left
Biceps 2+ 2+
Triceps . 2+ 2+
Supinator 2+ 2+
Knee 2+ 2+
Ankle - -
Plantar extensor extensor
A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 11, mechanical ventilator day 10
P: MRI
Day 7 (12/3/22):
S:- no fever spikes
O- O/E : patient is on mechanical ventilator
PEEP- 6
FiO2 - 30%
VT - 460ml
Timp : 1.9
VITALS:
temp- Afebrile
BP: 150/70mm hg
PR: 79 bpm.
RR: 17cpm
GRBS: 149mg/dl
spo2: 99% with Fio2 30%
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils : NSRL
GCS: E2VTM2
cough reflex: present
corneal reflex :negative
conjunctival reflex: present
doll's eye: negative
REFLEXES : right. left
Biceps 3+ 3+
Triceps . 3+ 3+
Supinator 3+ 3+
Knee 3+ 3+
Ankle 3+ 3+
Plantar extensor extensor
A: Seizures secondary to ? tuberculoma/?NCC with chronic hypoxic encephalopathy with post CPR status day 12, mechanical ventilator day 11
P : EEG
Day 8 (13/3/22):
S:- no fever spikes
O- O/E : patient is on mechanical ventilator
PEEP- 6
FiO2 - 25%
VT - 400ml
Timp : 1.9
VITALS:
temp- Afebrile
BP: 130/90mm hg @NORAD 4ml/hr
PR: 112 bpm.
RR: 14cpm
GRBS: 157mg/dl
spo2: 99% with Fio2 25%
CVS - S1, S2 heard ,no murmurs
RS. :- NVBS Present, no crepts
P/A: soft, non tender
CNS: Pupils : NSRL
GCS: E2VTM2
cough reflex: present
corneal reflex : present
conjunctival reflex: present
doll's eye: negative
REFLEXES : right. left
Biceps 3+ 3+
Triceps . 3+ 3+
Supinator 3+ 3+
Knee 3+ 3+
Ankle 3+ 3+
Plantar extensor extensor
A: Seizures secondary to ? tuberculoma/?NCC with severe hypoxic ischemic injury with post CPR status day 13, mechanical ventilator day 12
