75 YR OLD MALE ICU BED 1

75 YR OLD MALE 
ICU BED 1

Came with cheif complaints of 
INVOLUNTARY MOVEMENTS OF B/L UPPER AND LOWER LIMBS 
ASSOCIATED WITH FROTHING AND POSTICTAL CONFUSION.
NOT associated with tongue biting, aura, involuntary micturition or defecation.

H/O similar complaints in the past 
(Not on any medication).
 NO C/O chest pain, palpitations, shortness of breath, pedal edema, orthopnea, PND.

Not a k/c/o DM,HTN, ASTHMA,THYROID, TB.

PAST HISTORY:

Similar episode (GTCS) , associated with uprolling of eyes and frothing, happened one yr back, during sleep in the night , lasted for 2-3 min, followed by 5minutes postictal confusion , and later on he doesn't remember whatever happened.
They took to near by hospital , gave undocumented medication. No any imaging was done .
Got relieved.

After 6months ,  same episode was repeated.
They Came to our MEDICINE OP, advised few tests, after results , he was given unknown medication and used for 1week.
No any imaging was done .

And now again similar episode for third time.
All these three episodes happened during sleep in the night.

Occupation: 
works ( write records ) in gram panchayat.
He has three sons.
His wife expired 4months back due to high BP, after 1day of admission in nearby hospital.
He lives with his one of the sons.

He is  an ALCOHOLIC, since 35yrs , alternate days almost 100ml a day ,  From last 1yr ,  weekly twice same 100ml a day.

Smokes cigarettes occasionally. 

ALCOHOLIC , LAST BINGE YESTERDAY.

Personal history:

Takes mixed diet
Normal appetite
Adequate sleep
Regular bowel and bladder movements.
No known allergies.
ALCOHOLIC.
SMOKER

No significant family history.

O/E:
Pt is c/c/c
No pallor icterus, cyanosis, clubbing, lymphadenopathy, edema.
Temp:98.5f
Bp: 170/100mmhg
Pr:88bpm
RR: 18cpm
SPO2: 99% RA
GRBS: 145mg/dl

SYSTEMIC EXAMINATION:
CVS: S1S2+
RS: BAE +, NVBS +
P/A: soft, non tender
CNS: 
             RT.         LT
TONE 
    UL      N.            N
 
    LL      N.             N
POWER
  UL.      5/5.         5/5

 LL.        5/5.         5/5
REFLEXES:
           B.     T.       S.      K.      A.      P
 RT.     -.      -.         -.        -.       -.       M

LT.     -.        -.        -.         -.        -.      M

INVESTIGATIONS: 

PROVISIONAL DIAGNOSIS:

SEIZURES ( GTCS) UNDER EVALUATION.

Treatment:

Inj. LEVIPIL 1gm in 100ml i.v /stat
Inj. Pan 40mg i.v /stat.

PLAN OF CARE:
Tab. LEVIPIL 500mg PO/BDBD
Tab pan 40mg PO/OD
Inj.optineuron 1ampoule in 100ml NS i.v/ OD.
Inj lorazepam 2cc I.V /sos
Watch for seizure episode.
Monitor BP,PR,RR.

30/11/21

Planning for CT, EEG, 2decho

SOAP NOTES DAY 2

1/12/21
ICU BED 1

S:
no seizure episode
No fever spikes
stools not passed

O:
Pt is conscious, coherent
Afebrile
PR-96bpm
Bp-140/90mmhg
Spo2-98 % RA
RR: 14CPM
GRBS: 82MG/DL
I/O: 800/600ML
CVS: S1S2+
R/S: BAE+
P/A: soft,non tender
CNS:
oriented to T/P/P
Pupils: NSRL
EOM: full
Speech: naming, repetition, comprehension +
Fluency decreased.
Power - 5/5 in all LIMBS
Tone - normal
REFLEXES:
             B.       T.        S.       A.      K.       P.
Right.  -.         -.         2+.      -.       -.       Flexion.

Left.   -.         -.          2+.       -.      -.       Flexion.

A:

GTCS SEIZURES secondary to 
? ALCOHOL WITHDRAWAL.

P:
Inj thiamine100mg in 100ml NS i.v / TID.
Inj.lorazepam 2cc i.v/sos
Tab.levipil 500mg po/BD
Tab. Pan 40mg po/OD
Watch for seizure episode.
Temp charting
Monitor vitalsvitals 4th hrly.





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