75 yr female with c/onvoluntary movements of upper and lower limbs since 5 hours

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Chief Complaints:

Patient came to casualty with H/O 2-3 episodes of involuntary movements of right upper and lower limb and face since evening(28/10/23)

History Of Presenting Illness:

Patinet was apparently asymptomatic till today afternoon after she which she started having involuntary movements of right right upper and lower limbs associated with up rolling of eye balls and frothing not associated with involuntary micturation and defecation associated with postictal  confusion for 15-20min.

H/o seizure activity on and off from past 3years and is on medication.

No h/0 fever and head trauma.

K/c/o Hypertension,CVA

Past History:

N/k/c/o  DiabetesTuberculosis,bronchial asthma,epilepsy,CAD.

Personal History:

Diet : Mixed 

Appetite : Normal

Sleep : Normal

Bowel and bladder moments :Regular 

Addictions:None

Family History:

Not significant 

General physical examination:

Patient is unconscious 

Moderately built and nourished.

Pallor: Absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent 

https://youtu.be/gdOiN4BEoeI?si=BFxUZvx--VZukjxF

Vitals:

Temperature - 98F

PR :-78 beats per minute 

BP :- 150/100mm Hg

RR:-26 cycles per minute

GRBS:-135

SpO2-90%

Systemic examination:

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat felt in 5th intercostal space.

No parasternal heave and thrills

Auscultation-

S1S2 heard 

No murmurs heard

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.

-Palpation:

All the inspectory findings are confirmed.

Trachea central in position

-Percussion                Right              Left

Supraclavicular          R                   R

Infraclavicular           R                    R

Mammary                   R                    R

Inframammary          R                    R

Axillary                        R                    R

Infraaxillary               R                    R

Suprascapular           R                    R

Infrascapular             R                   R

R-Resonant

-Auscultation        Right              Left 

Supraclavicular     NVBS             NVBS

Infraclavicular       NVBS             NVBS

Mammary           Crepitations.     NVBS

Inframammary      NVBS              NVBS  

Axillary                    NVBS              NVBS

Infraaxillary      Crepitations.       NVBS

Suprascapular        NVBS              NVBS

Infrascapular         NVBS              NVBS

(NVBS- Normal vesicular breath sounds)

Central Nervous system:

GCS-E2V2M4

Tone           Rt.                 Lt

UL               N.                  N

LL.                N.                  N

POWER          Rt.                 Lt

UL                   5/5                 5/5

LL.                  5/5                  5/5

Reflexes         Rt.                   Lt

B                    ++                  ++

T                    ++                  ++

S                     +                  +

K                     +                 +

A                     +                 +

P                       Extension

Per Abdomen:

Soft,non tender 

No organomegaly

Investigations:

Liver Function test:

Total bilirubin-1.61mg/dl

Direct bilirubin-0.34mg/dl

SGOT- 9IU/L

SGPT-13IU/L

Alkaline phosphate-60

Total proteins-7.1g/dl

Hemogram:

Hemoglobin-12 gm/dl

Total count-13800cells/m3

PCV-34.6

RBC-4.32

Platelets:3L

Renal function test:

Urea-33mg/dl

Creatinine-0.7mg/dl

Uric acid -5.6mg/dl

Chloride-102

Sodium-139mEq/L

Potassium-4.1

RBS-115

CUE:

Sugar-nil

Albumin-nil

Pus cells-2-3

Cast cells-nil

RBC-nil

Epithelial cell-2-3

Serology-negative 

              

                

MRI : impression 

Chronic infract in left parieto occipital region.

Chronic small vessel ischemic changes

Provisional Diagnosis:

Focal Seizures with impaired awareness with CVA with k/c/o Hypertension.

Treatment:

1) IV fluids DNS,RL 75ml/hr

2) INJ LEVIPIL 1gm iv/od

3)INJ NEOMOL 1gm iv/sos

4)INJ PAN 40mg iv/od

5)INJ LORAZEPAM 2cc iv/sos

6)TAB ECOSPIRIN AV RT

7) TAB PCM 650mg RT/QID

8)NEB MUCOMIST 6th hourly

9) ORAL SUCTIONING 4th hourly

10)MONITOR VITALS

[11/3, 10:04] Swathi: SOAP Notes : icubed 1

3/11/23

S :  3 fever spike 10pm,12am,7am

Stools not passed

Bed sore grade _1

O : 

Patient is on  mechanical ventilation 

Vitals :

Temp : 100.1F

BP : 140/80 mmHg

PR : 110bpm

RR:15cpm

Spo2: 98%

A: 

Status epilepticus(resolved)

? Aspiration pneumonia 

K/c/o HTN SINCE 3 years

Post intubated state

P : 

1.IV FLUIDS dns,rl@75ml/hr

2. Rt feeds milk 50 ml/4th hourly, water 50ml 2 nd hourly

3.INJ AUGMENTIN 1.2 gm iv/bd

4.INJ LEVITRACETUM 1 gm iv 12 th hourly 

5 INJ Valproate 500mg iv 4th hourly 

6.inj optinueron1 amp in 100ml ns iv od

7.TAB pan 40mg iv /od

8.inj pcm 1gm iv/sos

9.tab Azithromycin 500 mg rt/od

11. Tab metxl  25mg rt/od

12.tab ecosporin av 75mg rt

13.nebulisation with mucomist,duolin_ 6th hourly

14.oral et tube suctioning 4th hourly

15.position change 2 nd hourly

16 compression stockings of bilateral lower limb

17.air bed

[11/4, 09:56] Swathi: Today ABG

SOAP Notes : icubed 1

4/11/23

S :  2 fever spike 8pm(3/11),8am(4/11)

Stools not passed

Bed sore grade _1

O : 

Patient is on  mechanical ventilation 

Vitals :

Temp : 100.1F

BP : 150/90 mmHg

PR : 99bpm

RR:20cpm

Spo2: 98%

A: 

Status epilepticus(resolved)

? Aspiration pneumonia 

K/c/o HTN SINCE 3 years

Post intubated state

P : 

1.IV FLUIDS dns,rl@75ml/hr

2. Rt feeds milk 50 ml/4th hourly, water 50ml 2 nd hourly

3.INJ augmentin 1.2 gm iv/bd

4.INJ Levitracetum 1 gm iv 12 th hourly 

5 INJ Valproate 500mg iv 4th hourly 

6.inj optinueron1 amp in 100ml ns iv od

7.TAB pan 40mg iv /od

8.inj pcm 1gm iv/sos

9.inj ceftriaxone 1gm iv/bd

11. Tab metxl  25mg rt/od

12.tab ecosporin av 75mg rt

13.nebulisation with mucomist,duolin_ 6th hourly

14.oral et tube suctioning 4th hourly

15.position change 2 nd hourly

16 compression stockings of bilateral lower limb

17.air bed  18.neosporin powder  for bedsore LA

SOAP Notes : icubed 1

6/11/23

S :  no fever spike 

Stools  passed

Bed sore grade _2

O : 

S/p exutubated state

Vitals :

Temp : 98.1F

BP : 140/90 mmHg

PR : 117bpm

RR:22cpm

Spo2: 100@5L o2

A: 

Status epilepticus(resolved)

? Aspiration pneumonia ( resolving)

K/c/o HTN SINCE 3 years

Exutubated state 

P : 

1.IV FLUIDS dns,rl@75ml/hr

2. Rt feeds milk + protein powder 150 ml/4th hourly, water 50ml 2 nd hourly

3.INJ ceftriaxone 1 gm  iv 12 th hourly 

4.INJ Levitracetum 1 gm iv 12 th hourly 

5 INJ Valproate 500mg iv 4th hourly 

6.inj linezolid 600 mg rt 12 th hourly 

7.TAB pan 40mg iv /od

8.tab metxl 25 mg rt/od

9.tab pcm 650 mg rt/tid

10. tab ecosporin av 75mg rt/hs

11.nebulisation with mucomist,duolin_ 6th hourly

14. Oral suctioning 4th hourly 

15.position change 2 nd hourly

16 compression stockings for bilateral lower limb

17.alpha bed  18.neosporin powder  for bedsore LA regular bed sore dressing

SOAP Notes : icubed 1

7/11/23

S :  no fever spike 

Stools  passed

Bed sore grade _2

O : 

Patient is conscious, cooperative 

Vitals :

Temp : 98.1F

BP : 140/90 mmHg

PR : 84bpm

RR:17cpm

Spo2: 98(RA)

A: 

Status epilepticus(resolved)

 Aspiration pneumonia (resolved)

K/c/o HTN SINCE 3 years

Exutubated state 

P : 

1.IV FLUIDS dns,rl@75ml/hr

2. Rt feeds milk + protein powder 150 ml/4th hourly, water 50ml 2 nd hourly

3.INJ ceftriaxone 1 gm  iv /bd 12 th hourly 

4.tab Levitracetum 1 gm rt/bd 12 th hourly 

5 tab Valproate 500mg RT/bd 12 th hourly

6.tab linezolid 600 mg rt 12 th hourly 

7.TAB pan 40mg rt /od

8.tab metxl 50 mg rt/od

9.tab pcm 650 mg rt/tid

10. tab ecosporin av 75mg rt/hs

11.nebulisation with mucomist,duolin_ 6th hourly

14. Oral suctioning 4th hourly 

15.position change 2 nd hourly

16 compression stockings for bilateral lower limb

17.alpha bed  18.neosporin powder  for bedsore LA regular bed sore dressing

Abg (room air) 7/11/23

pH: 7.48

Pco2: 36.1

Po2:59.2

Hco3: 27.9

So2: 92.1%