65 years old male patient with involuntary movements and focal seizures

  65 year old male patient with Involuntary movements and focal 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- 28/06/2023

A 65 year old male patient brought to casuality by his attenders with chief complaints of 
Involuntary movements of left upperlimb and frothing from mouth at 4 10 am on 28/06/2023


HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic till 4 10 am 
Then he developed involuntary movements of left upperlimb and frothing from the mouth since 1 hr 
Associated with uprolling of eyes and involuntary micturiion present 
Involuntary movements of left lowerlimb were also present in casuality
No involuntary movements of right  upper and lowerlimbs 
No involuntary defecation 
Post ictalconfusion present 
No tongue bite present 
Patient was not responding to commands 


HISTORY OF PAST ILLNESS

History of similar complaints in the past 
11/07/21 - c/o weaknesss of upper and lower limbs , involuntary contraction  of hip muscles ,generalized weakness and was daignosed with dystonia secondary to metabolic cause ( uncontrolled sugars ) 
13/03/22 - c/o loss of speech and unresponsive weaknesss of left upper and lower limbs , deviation of mouth to right. Mri was done and showing subacute to chronic infarct in right parietal and occipital lobes of brain and diagnosed with seizures secondary to old cva with todds palsy 
18/04/22 - involuntary movements of left upper limb  and daignosed with focal seizures secondary to hyperglycemia  
18/01/2023 - focal seizures with secondary generalization 
Old CVA 2 years back ( right parietal and occipital lobes ) infarct 
AKI on CKD non oliguric ( post renal ) resolved 
Secondary to paraphymosis 
cervical spondylosis with cervical myelopathy with UTI 
K/c/o seizures disorder since 2 years 
Diabetic milletus:- 6 years - on medication ( insulin)





PERSONAL HISTORY 

   Occupation:. Farmer

    appetite : normal 

     Diet : mixed

Marital status : married

Bowel movement  : regular      

Micturition: normal


FAMILY HISTORY

No relevant family history 
      

GENERAL EXAMINATION 

Patient is conscious, coherent, co-operative.


There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy and edema


SYSTEMIC EXAMINATION:

Cardiovascular System

Thrills-  no

Cardiac sounds- S1, S2  +

Cardiac murmurs - No

RESPIRATORY SYSTEM

Position of trachea- central

Breath sounds- vesicular

No Dyspnea and wheeze


ABDOMEN

Shape of abdomen- scaphoid

 tenderness - no 

Palpable mass- no

Free fluid- no

Bruits- no

Liver- Not palpable

Spleen- Not palpable

Bowel sound- Yes

CENTRAL NERVOUS SYSTEM 

Patient is drowsy

Speech - slurred 








Cerebellar  signs :- finger and nose in cordination -- no
Knee and heel in coordination -- no
Examination of head and neck :- neck stiffened












Ecg - 





Investigations - 



















Treatment - 

1 inj levipil 1 gm / iv / bd 
2 tab sodium valproate 1000mg/ po bd 
3 iv fluids ns 
4 tab phenytoin 100 mg po/bd 
5 tab ecosprin + atorvastatin  75 mg po / hs 
6 inj HAI  sc/ tid
7 inj kcl 1amp in 500 ml ns over 5 hours 
8 monotor vitals 


30/6/23 
AMC 3
Dr .Nikitha (SR) 
Dr. Pavan(PGY2)
Dr. Lohith (PGY1)

S 

 Pt is drowsy 
Did not pass stools

O 

Patient is drowsy 
Speech slurred
Temp : Afebrile 
BP : 120 /80 mmHg 
PR : 80bpm 
RR : 24cpm 
CVS :  S1, S2 + 
RS : BAE + 
P/A : Soft , Non Tender 
CNS : 
                    Rt                     Lt 
Tone : UL - Normal     Normal 
            LL -  Increased     Increased 
Power : UL - 5/5               
Flickering
               LL-  5/5                3/5 
Reflexes : B : ++                +++
       Triceps : +++               +++             
           Knee :  ++                 +
         Ankle  :  ++            + ++
     Supinator : -                  ++
      Plantars : Extensor          Extensor
GRBS :
2 AM-188mg/dl
8 AM-204mg/dl


A 

Recurrent left Focal Seizures with Secondary Generalisation 
Chronic hypokalemia 
Chronic kidney disease  Oliguric (Post Renal ) ,
K/C/O DM-2 Since 6yrs 
K/C/O Epilepsy since 2 years 
H/O CVA(Left hemiparesis  (left hemiparesis -infarct) 2 years ago


P
RT FEEDS 200ML WATER 2ND HOURLY, 200ML MILK 4TH HOURLY
INJ.LEVIPIL 1GM/IV/BD
IV FLUIDS NS@UO + 30ML/HR
T. PHENYTOIN 100MG  RT/BD 
T. SODIUM VALPROATE 1000MG RT/BD 
TAB.ECOSPIRIN+ATORVASTATIN 75MG/RT/HS AT 9 PM
INJ.HAI ACCORDING TO GRBS SC/TID
INJ KCL 20 MEQ IN 500ML NS IV SLOWLY OVER 5 HRS
GRBS 7. PROFILE
MONITOR VITALS 2ND HOURLY






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