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A 48 year old male with seizures and altered sensorium

I have been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan. 


A 48-year-old gentleman hailing from a small town in Telangana presented to the casualty ward on 25th April 2021 at 7:40am with the chief complaints of unresponsiveness for 7 hours and 3 intermittent episodes of seizures in the past 3 hours

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 7 hours ago(at 1am) when he suddenly became drowsy and stopped responding to verbal instructions.

Nearly 3 hours later (at 4am) he developed involuntary jerky movements on all four limbs, without regaining consciousness in between. He had 3 such episodes in total in a span of 3 hours. The duration of each episode is not known as the attendant failed to recollect the exact events

He has a history of binge drinking 3 hours prior to the onset of drowsiness ie. at 10pm on 24th April 2021. 

A CT scan of the brain and an ECG were ordered as a part of the investigation. The CT scan showed an acute cerebral hemorrhage of the frontal, parietal and temporal lobes with a 13mm midline shift. It was decided that the patient requires neurosurgical intervention and he was referred to a higher center after informing his attendants. The patient was discharged from hospital#1 at 10:30am on 25th April 2021. 

The patient reportedly lost complete consciousness on the way to the referred hospital#2. On arrival at hospital#2, he was redirected to another hospital due to a shortage of beds.

At hospital#3, it was apparently declared that the patient had become comatose. He was intubated for mechanical ventilation. Medical management given at hospital#3 is not known.
He stayed at hospital#3 till he reportedly died from a second case of intracranial bleeding on 25th April 2021.


PAST HISTORY

History of multiple falls when inebriated and history of minor head injuries that were left unattended. History of change in gait since 1 year

No history of fever, neck rigidity, or persistent headache

No history of Covid

Not a known case of Hypertension, Diabetes, Asthma, or Epilepsy.  


PERSONAL HISTORY

Diet: Mixed

Appetite: Normal

Sleep: Normal

Bowel, bladder: Regular

Addicted to alcohol for the past 3 years. According to the attendant he used to drink "a few bottles per day". Drinks both bottled liquor and toddy. 


DRUG HISTORY

No known drug allergies. 


FAMILY HISTORY

No similar complaints in the family

No history of epilepsy, diabetes, hypertension, asthma, or TB in the family


GENERAL EXAMINATION

At the time of admission, on examination in a well-lit room and with the informed consent of the patient's attendant
 
  • The patient is conscious with altered sensorium
  • He was moderately built and well-nourished

    Pallor: Absent

    Icterus: Absent

    Cyanosis: Absent

    Clubbing: Absent

    Lymphadenopathy: Absent

    Edema: Absent

Vitals: On admission, 

Temperature: Afebrile

PR: 102bpm

BP: 150/90mmHg

SpO2: 62% at RA

GRBS: 156mg%


SYSTEMIC EXAMINATION

Respiratory System: Bilateral air entry positive

CVS: s1, s2 heard

CNS: Altered sensorium noted, E1V1M1

P/A- Soft, non-tender


INVESTIGATIONS

1) ECG (25/04/21)






2) CT Brain (taken on 25/04/21)








 PROVISIONAL DIAGNOSIS

Generalized tonic-clonic seizures secondary to acute hemorrhage in the frontal, temporal, and parietal lobes with a 13mm midline shift

TREATMENT ADMINISTERED


Ryles Catheterization

Head end elevation, Oxygenation

INJ Lorazepam stat 2CE

INJ Levetiracetam 1gm IV stat

INJ Mannitol 100ml IV stat

INJ Thiamine 1 ampoule in 100ml normal saline IV stat


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