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GENERAL MEDICINE E-LOG

NAME: A. SANVITH

ROLL NO: 09

A 61Y/M with Seizures secondary to Intracranial bleed , ?Atypical Pneumonia , With k/c/o HTN Denovo DM





INTRODUCTION:
61 year old male, farmer by occupation came to the casuality with..
CHIEF COMPLAINTS OF:
Altered state of consciousness since 
1 week. 

HISTORY OF PRESENT ILLNESS:
Chronic alcoholic since 20 years, regular alcohol/Toddy drinker
Patient was apparently asymptomatic 6 years back then he had giddeness and weakness of left upper limb and lower limb and he got admitted in hospital ,at that time he was diagnosed with hypertension and CT brain was done -Rt internal capsule bleed secondary to hypertension.

He was apparently asymptomatic 1 week back and he had done his work in farm and ate food during night time and went sleep then he developed episode of involuntary movements of all 4 limbs with 
          uprolling of eyes,
          froath from mouth +
          Involuntary micturition+
          Tounge bite +
          Shortness of breath+
          Abdominal distension with tightness.
Post-ictal confusion last for 3 days
Patient was admitted in Hyderabad hospital with above complaints and At that time his

VITALS:
BP:170/100mmhg
PR:132/min
Spo2:84%.
HISTORY OF PAST ILLNESS:
K/C/O Hypertension since 6 years
No H/o diabetes,asthma ,epilepsy

INVESTIGATIONS:
RBS:310mg/dl
HbA1C:12.3
Cr:1.8
Na:138
K:35
Alb:2.7
MRI brain with venogram- Subacute Lacunar infract, Right Temporal bleed
CT chest- Atypical Pneumonia
2D echo- EF 60%


On presentation, pt was drowsy with E4V2M4



On examination: 
Pt is  drowsy 
Febrile to touch:100.4F
PR: 112bpm
BP: 140/90 mmHg
Spo2:84% and 95% with 15L of O2
GRBS:238mg/dl
CVS: S1, S2 heard
RS: BAE present ,B/L coarse crepts present in all areas
P/A: soft ,non tender ,bowel sounds present
CNS: E4V2M4
Tone : normal b/l
Reflexes:
       Lt.      Rt
B.    3+.    3+
T.     3+.    3+
S.    1+.     1+
K     3 +.    3+
A.    3+.     3+

Investigations:

On: 29/09/2021

Dengue NS1 Antigen,IgG and IgM(RAPID TEST)

HIV 1/2 Rapid Test

HBsAg- Rapid

Anti HCV Antibodies Rapid

Blood Urea

Phosphorus

Serum creatinine

ESR RATE

Uric Acid Serum

Serum Magnesium


Hemogram

Liver function test(LFT)

APTT

Blood grouping and RH TYPE

On 30/09/21:
ABG

On 02/10/21:

CBP

On 03/10/21:

HEMOGRAM


SERUM ELECTROLYTES

SERUM CREATININE

BLOOD UREA

Radiological investigations:







PROVISIONAL DIAGNOSIS:
?Seizures secondary to Intracranial bleed ,
?Atypical Pneumonia ,Denovo DM

Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)Tab.PCM 650 mg RT/TID
4)Tab.Levipil 500mg RT/TID
5)Tab.Montair-LC RT/OD
6)PULMOCLER RT/OD
7)Clindamycin 300mg/PO/TID
8)Tab.Librium 25 mg /PO/OD
9)Tab.Stamlo 5mg/PO/OD
9)Nebulization with Budecort 6th hrly
                                     Ipravent 2nd hrly
10) Monitoring vitals 4th hrly
11) GRBS charting 6th hrly
12)I/O and Temperature charting

Plan of care:

*SOAP NOTES-02/10/21

    A 61 YEAR OLD MALE

   S-
   pt was drowsy with E4V2M4



   Objective
     Pt is  drowsy 
     Afebrile
     PR: 93bpm
     BP: 140/100 mmHg
     GRBS:243mg/dl
     CVS: S1, S2 heard
     RS: BAE present ,B/L coarse crepts present in all areas
     P/A: soft ,non tender ,bowel sounds present
     CNS: E4V2M4
     Tone : normal b/l
     Reflexes:
       Lt.      Rt
B.    3+.    3+
 T.     3+.    3+
 S.    1+.     1+
  K     3 +.    3+
  A.    3+.     3+
  
    ASSESSMENT-
                                  

?Seizures secondary to Intracranial bleed ,
          ?Atypical Pneumonia ,
          With k/c/o HTN
          Denovo DM
          
Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)INJ.levofloxacin 500 mg iv/od
4)INJ.hai s/c tid
5)Tab.PCM 650 mg RT/TID
6)Tab.Levipil 500mg RT/TID
7)TAB.PULMOCLER RT/OD
8)TAB.Clindamycin 300mg/RT/TID
9)TAB.LEVIPIL 500 Mg RT/TID
10)Tab.Stamlo 5mg/PO/OD
11)Nebulization with Budecort 6th hrly
                                     Ipravent 2nd hrly
 12) Monitoring vitals 4th hrly
 13)  GRBS charting 6th hrly
 14)I/O and Temperature charting
 15) Chest physiotherapy

*Soap notes-03/10/21
    S-
    pt was drowsy with E4V2M4
Objective
   Pt is  drowsy 
   Afebrile
   PR: 95bpm
   BP: 140/100 mmHg
   GRBS:169mg/dl
   CVS: S1, S2 heard
   RS: BAE present ,B/L coarse crepts present in all areas
   P/A: soft ,non tender ,bowel sounds present
   CNS: E4V2M4
   Tone : normal b/l
    Reflexes:
       Lt.      Rt
 B.    3+.    3+
 T.     3+.    3+
 S.    1+.     1+
 K     3 +.    3+
 A.    3+.     3+
  
  ASSESSMENT-
                                  

?Seizures secondary to Intracranial bleed ,
          ?Atypical Pneumonia ,
          With k/c/o HTN
          Denovo DM
          
Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)INJ.levofloxacin 500 mg iv/od
4)INJ.hai s/c tid
5) INJ Mannitol
6)Tab.PCM 650 mg RT/TID
7)Tab.Levipil 500mg RT/TID
8)TAB.PULMOCLER RT/OD
9)TAB.Clindamycin 300mg/RT/TID
10)TAB.LEVIPIL 500 Mg RT/TID
11)Tab.Stamlo 5mg/PO/OD
12)Nebulization with Budecort 6th hrly
                                     Ipravent 2nd hrly
 13) Monitoring vitals 4th hrly
 14)  GRBS charting 6th hrly
 15)I/O and Temperature charting
 16) Chest physiotherapy

*Soap notes-04/10/21

   S- pt is drowsy


   Objective:
     Pt is  drowsy
     Afebrile
     PR:96 bpm
     BP: 130/90 mmHg
     CVS: S1, S2 heard
     RS: BAE present ,B/L coarse crepts present in all areas
     P/A: soft ,non tender ,bowel sounds present
     CNS: E4V2M4
     Tone : normal b/l
     Reflexes:
       Lt.      Rt
B.    3+.    3+
T.     3+.    3+
S.    1+.     1+
  K     3 +.    3+
  A.    3+.     3+
 
ASSESSMENT-
                                 

?Seizures secondary to Intracranial bleed ,
          ?Atypical Pneumonia ,
          With k/c/o HTN
          Denovo DM
         
   Plan of care:
    1)Head end elevation
    2)O2 inhalation to maintain Spo2 >94%
    3)INJ.levofloxacin 500 mg iv/od
    4)INJ.hai s/c tid

    5) INJ Mannitol

    6)Tab.PCM 650 mg RT/TID
    7)Tab.Levipil 500mg RT/TID
    8)TAB.PULMOCLER RT/OD
    9)TAB.Clindamycin 300mg/RT/TID
    10)TAB.LEVIPIL 500 Mg RT/TID
  11)Tab.Stamlo 5mg/PO/OD
   12)Nebulization with Budecort 6th hrly
                                     Ipravent 2nd hrly
   13) Monitoring vitals 4th hrly
   14) GRBS charting 6th hrly
   15)I/O and Temperature charting

    16) Chest physiotherapy

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