GENERAL MEDICINE CASE DISCUSSION of 17 year old female

 This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.


Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
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.

Case Scenario:


A 17 year old female student by occupation presented to causality on 1/5/2021 with
Chief complaints of
1.Involuntary movements of both upper and lower limbs a day before.

History of present illness:

Patient was apparently asymptomatic one day ago, then she  developed recurrent involuntary movements of all four limbs associated with loss of consciousness and frothing. And  with recovery of consciousness in between episodes with post ictal confusion lasting for 30 secs to few minutes.

No. of episodes are 5 to 6 in 24 hours.

she first visited hospital 1 And was then  referred to hospital 2 for further management.

She continued to have multiple GTCS episodes with a frequency of one in 20 minutes.

She also complained of
*Headache which was right sided,intermittent ,dull aching type.
*vomitings:1 episode of vomiting bilious,containing food particles.
*No h/o involuntary micturition,No h/o involuntary defecation 
*No H/o tongue bite.
*No H/o fever,cough,SOB,chestpain,sweating.
*No H/o weakness  of limbs.


,PAST HISTORY:

No H/o similar complaints in the past
Not a known case of Hypertension ,TB,Bronchial Asthma,thyroid, CAD.

TREATMENT HISTORY

Not on any medication

SURGICAL HISTORY:
NO H/O any surgeries in the past

 PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep:Adequate
Bowel and bladder movements: Regular
Allergies:No
Addictions:No

FAMILY HISTORY:
No H/o Similar complaints in the family.
Her father is  a known case of hypertension since 2years.

MENSTRUAL HISTORY:
Age of menarche: 13 years
Menstrual cycle: Regular

PHYSICAL EXAMINATION:
Patient is conscious coherent and cooperative 
Moderately built and moderately nourished 
 Well oriented to time place and person

VITALS 
TEMPERATURE: Febrile
Pulse rate: 89bpm
BP: 110/80 mmhg
Spo2:99%. At room air

Pallor present 
No icterus 
No cyanosis 
No clubbing 
No lymphadenopathy
No edema

SYSTEMIC EXAMINATION:

CNS EXAMINATION 

She is conscious  coherent and coperative
Speech: Normal
No neck stiffness 
Kerning sign: negative
Power and tone :Normal

Reflexes:

Biceps:   Right +++ Left+++
Triceps:Right +++ Left+++
Supinator:Right +++ Left+++
Knee:Right +++ Left+++
Ankle:Right +  Left+


CVS EXAMINATION:
Cardiac sounds S1 S2 heard
No murmers  heard 

 RESPIRATORY SYSTEM 
Normal vesicular breath sounds heard
Trachea: central
No wheeze
 
ABDOMEN EXAMINATION:
Shape of abdomen: scaphoid
No tenderness 
No palpable mass
Liver not palpable
  
INVESTIGATIONS:
MRI
HEMOGRAM
RFT
RBS
CHEST XRAY 
COMPLETE URINE EXAMINATION 
LIVER FUNCTION TESTS 
ECG
      1/5/21
RBS:



CUE:
HBSAg:
HIV Test:
CBP:
Impression:Microcytic hypochromic anemia with lymphocytic leucocytosis.

CUE
2/5/21
SERUM ELECTROLYTES



CBP

CBP:
Impression:Microcytic hypochromic anemia with leucocytosis.

3/5/21


PROTHROMBIN TIME:


APTT TEST
4/5/21
RENAL FUNCTION TEST:
Decreased sodium.

LIVERFUNCTION TESTS:
*AST elevated
Total protein and albumin are less than normal.

ABG

5/5/21

SERUM ELECTROLYTES
Potassium #3.4 decreased.


ABG






6/5/21


PROTHROMBIN TIME:


7/5/21

ABG:

LIVER FUNCTION TESTS:
AST ALT elevated
Total protein and albumin levels reduced.




LIVER FUNCTION TESTS 
AST ALT elevated
Total protein and albumin levels decreased.


ABG


RFT 


CBP


Microcytic hypochromic anemia.


11/5/21


15/5/21





MRI on 2/5/21


IMPRESSION ON MRI:F/S/O Acute cortical vein thrombosis  with hemorrhagic venous infarction involving  Right posterior temporal lobe with midline shift to left by 4mm.

ECG



Diagnosis:


Recurrent seizures(seizure clusters/status epilepticus)resolved secondary to cortical vein thrombosis with hemorrhagic venous  infarction in right posterior temporal lobe with (4mm midline shift).
Iron deficiency anemia.


 


 TREATMENT:
1.Inj Levipil 1gm in 100ml NS IV STAT 
                        
Inj Levipil 500mg iv BD
2.Inj Lorazepam iv sos
3.Inj sodium valproate 800mg/iv/stat
 Inj phenytoin 800mg iv/stat 
4.Inj  Midazolam 0.2 mg/kg/hr
 Accordingly Upto 2mg/kg
5.Inj Clexane 0.4ml s/c BD
6.Inj Dexamethasone 4mg TID
7.Inj Mannitol 100ml iv/BD
8.RT Feeds 100ml water hourly 
50ml milk 2nd hourly 

On 2/5/21 
Patient is conscious  coherent cooperative.
 Afebrile to touch.
Rt sided parietal  area headache.
No photophobia no vomiting.
O/E:
Pupil normal Response to light.


On 3/5/21
Seizures GTCS 7 episodes and 1 episode  of high grade fever on 2nd may night .
Last seizure episode on 3rd may 9: 30 am 
Decreased by inj phenobarbitone 20mg/kg-800 mg iv stat
 Consciousness present  in inter ictal period. 
O/ E :
pt is sedated responding to painful stimuli.
E3v3M5
Pupils B/l pinpoint secondary  to BZD
FEBRILE 100 F

On 4/5/21
Pt was intubated last night for recurrent seizures 
Last seizure episode  10:30 pm before intubation
2 episodes of high grade fever last night
Hiccups present, edema and thrombophlebitis present.
Did not pass stool since 3 days
O/E 
Febrile 100 F
Pt  was sedated,moving intermittently. 
Pupils pinpoint non reactive  to light
Gcs:E1VTM2

On 5/5/21

Seizure free period 36hrs 
High grade intermittent fever
Intermittent movement present,Thrombophlebitis and edema present.
Hiccups decreased.
O/E 
Patient is sedated
 E1VtM2
Temp:102.7 F



On 6/5/21
High grade fever every 4 to 5 hrs 
Seizures free period 2 days
Intermittent movement present,Thrombophlebitis and edema present.
Stools not passed  since 4 days

0n 7/5/21 
 fever  frequency reduced
Seizures free period 72 hours
Intermittent movement present,
Thrombophlebitis and edema present.
Stools not passed  since 5 days
O/E
Pt E4VTM6
CNS No abnormality detected 
Spo2 99% on CPAP mode

On 8/5/21 
 Extubation yesterday
High grade fever continuosly every 4hrs 
O/E 
Febrile to touch 100. 2F
CNS HMF intact
Power: 4/5 in all limbs 
Handgrip:70% b/l


On 9/5/21 
S/p extubation
High grade fever  every 4hrs

O/E
 Febrile to touch 100F
 CNS HMF intact
Power 4 /5  in all limbs
Handgrip 80% Bilateral 

On 10/5/21
Sensorium improved 
Fever spikes reduced

 On 11/5/21
1 episode of GTCS yesterday on 10th may
O/E CNS No abnormality detected 
 
12/5/21  13/5/21  no fresh complaints 

14/5/21 
Rx oral fluids 4 to 5 lit/ day
Encourage soft diet
Inj LEVIPIL 1gm/ iv/bd
Inj sodium  valproate 1 gm  100ml NS/IV/Bd

15/5/21 no fresh complaints 

16/5/21 Seizure free period  since 5days
No new symptoms 
O/E patient conscious and afebrile
 HMF Intact 
NO FND
Fundus:No papilledema

Rx change from injections to tablets 

Tab sodium valproate 1gm/po/BD
T.levitiracetam 1gm/po/BD
T.ACITROM 2mg/po/OD
INJ CLEXANE 4Omg /sc/BD
T.FRISIUM 5mg/PO/OD 8.00 am
Inj Mannitol 20gm /iv/OD
T.OROFER XT /po/BD

17/5/21
Seizure free period  since 6days
No new symptoms 
O/E patient conscious and afebrile 
HMF Intact 
NO FND

18/5/21
Seizure free period  since 7 days 
Headache  yesterday night got resolved  
No new symptoms 
O/E patient conscious and afebrile
HMF Intact 
NO FND.
  
19/5/21
Seizure free period  since 8 days.
CNS Higher Mental Function intact.
Rx Levipil 500mg/po/TID

COURSE IN HOSPITAL 
Initially Patient  was given inj Lorazepam 8mg iv stat Leviteracetam 1gm iv stat,inj sodium valproate 800mg stat started on inj Midazolam 0.2mg/kg/hr and escalated upto 2mg/kg/hr,inj Clexane 0.4ml/sc was started in suspicion of CSVT,inj Mannitol 20gmTID.

Patient continued to have seizures with decreased frequency 9thday .
MRI was done on 2/5/21 with venogram which showed cortical venous thrombosis and hemorrhagic venous infarction in post temporal.

Fundoscopy showed papilloedema in the right eye. patient was given inj phenobarbitone 20 mg/kg stat 800mg in view of recurrent seizures and need for further sedation. 

Patient was electively intubated on 4/5/21  and dose of Midazolam was increased till seizure free period was achieved.
Also continued on anticoagulantion and other antiepileptics.

3 days after seizure free period  patient was tapered off Midazolam, phenobarbitone and extubated on 8/5/21.
And continued  on same treatment.
She had one episode of GTCS again on 10/5/21 resolved spontaneously. 
She was shifted back to ICU where she was monitored Tab Acitrom 2mg was started on 16/5/21 once daily and clexane tapered off.

Possible Questions 

Possible questions:1.  what can be  the cause of her condition ? 
   2. what are the risk factors for cortical vein thrombosis?  
3.There was seizure free period in between but again sudden episode of GTCS why?resolved spontaneously  why? 
4. What drug was used in suspicion of Cvst?



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