KAVYASREE 04 [OLD BATCH]

 Greetings to one and all who are reading my blog.This is K.KAVYA SREE,Rno-04 [old batch],a

 Third semester student.


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------

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