N.lavanya
2019 Internee
A 80 year old female who is a homemaker was brought to casualty with unresponsiveness with h/o involuntary movements of both upper limbs since 11pm previous night, 5-6 episodes lasting for 15mins
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A 80 year old female who is a homemaker was brought to casualty with unresponsiveness with h/o involuntary movements of both upper limbs since 11pm previous night, 5-6 episodes lasting for 15mins without regaining consciousness in between, not associated with uprolling of eyes, frothing, tongue bite, involuntary micturition
H/o fever since evening high grade with chills, relieved on taking Dolo tablet
No h/o vomitings, headache, chest pain, palpitations, breathlessness, pain abdomen, decreased urine output,pedal edema
She is the 3rd child, got married(non consanguinous) at 12 yrs age,given birth to female baby at 18-19 yrs age by vaginal delivery
At 25 yrs of age she has a fall from by bike slipping, then started complaining of back pain on and off used pain medications on and off prescribed by local practitioners
In 2014 she has got first seizure episode during sleep with involuntary movements of both upper limbs and lower limbs, with uprolling of eyes, frothing, tongue bite, involuntary micturition with post ictal confusion,around 4-5 episodes, then taken to neurologist, MRI was done but they were told nothing about the cause, and were told it can be because of Hypertension and started on Tab TelmaH 40/12.5
For seizures she was started on tab sodium valproate 700mg bd, tab levipil 500mg bd, tab clobazam 5mg bd. She has used them for some period and taken only some of them because she doesn't want to take so many medications
She has got seizure episodes once in 3mnths, once in 6mnths for around 3-4yrs all episodes during sleep involving all four limbs with frothing, involuntary micturition, uprolling of eyes, post ictal confusion, and generalised weakness the next day when she missed taking medication, after that no seizure episodes
In 2017 again CT was done, they were told nothing was significant, it is because of Hypertension, she was told there is need of angio but can't be done because of her age, treadmill test was performed but unable to do
She has stopped taking medication completely after her husband's demise in 2019
In 2019 she has got seizure episode in sleep, and then taken to general physician, started on Levipil 500 mg bd, tab FascismT (? Tinidazole) bd, used for only a week to 10days, used only clobazam 5mg and telmaH. Her Hb was 5.4, creat 1.1
Her husband has got seizures in 1985, in 2013 but less severe than the wife
Her daily routine
Wakes up in between 6:30- 7, takes tea at 7:30, does her household work (cooking, washing clothes) takes bath between 9-10am, eat breakfast, do her household work, takes lunch at 2pm, takes rest, drinks tea at 4pm, starts her household works, dinner at 8:30pm, goes to bed at 10-11pm
PAST HISTORY
Known case of hypertension since 5 years on Tab TelmaH 40/12.5
K/c/o seizures since 10 yrs
For seizures she was started on tab sodium valproate 700mg bd, tab levipil 500mg bd, tab clobazam 5mg bd.
No history of diabetes mellitus, asthma, cardiovascular disease ,tuberculosis
no history of blood transfusions.
Personal history
Married
Mixed diet
Sleep adequate
Bowel-Regular
Bladder-Irregular
No allergies known
Occasionally consumes toddy
Family history :
Not significant
General examination
The patient is conscious coherent cooperative
Well oriented to time place and space
Moderately built and nourished
No Pallor
No pedal Odema
No Clubbing
No icterus
No lymphadenopathy
Vitals
Temp:100.51°F
PR: 122bpm
Rr: 14/min
Bp:110/90 mm Hg.
Spo2: 95
GRBS:144mg
CNS examination
B/L pupils not reacting to light
Tone in upper limbs increased
Lower limb normal
Power - not elicited
REFLEXES-absent
Dolls eye present
Corneal conjunctival present
CVS-S1,S2+ ,NO MURMURS
GCS E1vtM3
RESPIRATORY SYSTEM-BAE+ NVBS
Per Abdomen:
-no tenderness
-No palpable mass
-Spleen : not palpable
-liver : not palpable.
Investigations
On 7/5/24
On8/5/24
On 9/5/24
Chest X-ray on 7/5/24
2D echo report
ECG on 7/5/24
ECG on 7/5/24
ECG on 9/5/24
MRI report
ABG @ 7pm on 7/5/24
ABG @3 pm on 7/5/24
ABG on 8/5/24
@ 3Am
Provisional diagnosis
Status epilepticus
K/c/o seizures disorder since 10 yrs
K/c/o HTN since 10 yrs
HFmEF(EF 45%)
Managment
On 7/5/24
Inj levipil 500 mg iv /stat
Inj Neomol 1 mg iv /stat
Inj levipil 1 gm iv/ bd
Inj pan 40 mg iv /od
Inj zofer 4 mg iv /TID
Inj ceftraxone 1gm IV /BD
Inj fentanyl 4 ml + Inj Midazalom 30 ml in 16 ml NS @ 5 ml / hr
Inj atracurium 2 amp in 45 ml NS @ 5 ml /hr
Inj LASIX 20 mg iv/TID
ET tube suctioning 2 hrly
Position change 2 hrly
Monitor vitals 2 hrly
Mangement on 8/5/ 24
Head end elevation at 45
Iv fluids NS @ 50 ml/hr
Inj Neomol 1 mg iv /stat
Inj levipil 1 gm iv/ bd
Inj pan 40 mg iv /od
Inj zofer 4 mg iv /TID
Inj ceftraxone 1gm IV /BD
Inj fentanyl 4 ml + Inj Midazalom 30 ml in 16 ml NS @ 4 ml / hr
Inj noradrenaline 2 Amp in 46 ml NS @ 7 ml /hr
Inj atracurium 2 amp in 45 ml NS @ 5 ml /hr
Inj dobutamine 1 amp in 45 ml NS @ 1 ml / hr
Inj LASIX 100 mg in 40 ml NS
Tab Ecosprin gold 75/75/20 RT
ET tube suctioning 2 hrly
Position change 2 hrly
Monitor vitals 2 hrly
Syp potklor 10 ml in glass of water po TID
Tab MET -XL 12.5 mg RT/OD
Elastic stockings for b/l LL
Management on 9/5/24
Head end elevation at 45
Iv fluids NS @ 70 ml/hr
Inj Neomol 1 mg iv /stat
Inj levipil 1 gm iv/ bd
Inj pan 40 mg iv /od
Inj zofer 4 mg iv /TID
Inj ceftraxone 1gm IV /BD
Inj fentanyl 4 ml + Inj Midazalom 30 ml in 16 ml NS @ 4 ml / hr
Inj noradrenaline 2 Amp in 46 ml NS @ 7 ml /hr
Inj atracurium 2 amp in 45 ml NS @ 5 ml /hr
Inj dobutamine 1 amp in 45 ml NS @ 1 ml / hr
Inj LASIX 100 mg in 40 ml NS
Tab Ecosprin gold 75/75/20 RT
ET tube suctioning 2 hrly
Position change 2 hrly
Monitor vitals 2 hrly
Syp potklor 10 ml in glass of water po TID
Tab MET -XL 12.5 mg RT/OD
Elastic stockings for b/l LL
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