75 year old daily wage worker.

Note: 

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(Under the guidance of  Dr. Vinay sir (PG), and Dr. Kusuma ma'am  intern)

75-year-old daily wage laborer.

Brought to hospital at 4:00pm on 4/7/21

Chief complaint-

• Patient came to casualty in drowsy state since 3pm
• patient was in altered state from morning  
• C/o history of involuntary defecation 1 episode in the morning

History of presenting illness-

• He was apparently asymptomatic 6 months back 
• He development hematuria 20 days after which they went to Gandhi hospital where he was diagnosed with prostate cancer (adenocarcinoma) for which a surgery (bilateral orchidectomy)  was done and then referred to MNJ hospital for further treatment. 
• He also had history of 1 episode of GTCS 6 months back with involuntary movements, lip bite, frothing from mouth, involuntary micturition which was treated  and patient was in confusion for 2 days.
• Since then he was on tab. Levipill 500mg po/bd
• At the same time he was admitted in hospital as he was diagnosed hyponatremia and was treated.
• Then he was referred to MNJH hospital and was diagnosed for prostate cancer (Adenocarcinoma) . For pain he was given morphine ½ tablet 2 hourly and 1 tablet at night. 
• Today after taking morphine patient was unconscious from morning and was drowsy from 3 pm   
• History of involuntary defecation in the morning

Family history- 

• Patients brother and 2 children suffer from mental disability

·    Examination- Objectively-

• Mild Pallor

• No Icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy
• PR 88 bpm
• RR 22 cpm
• BP- 110/60 mmHg
• GRBS- 110
• SpO2- 87% at room air
• CNS- Drowsy arousable, no focal deficit
• Power- 

                   UL      LL

           Lt    4+/5    4+/5

           Rt    4+/5    4+/5

• Patient became conscious around 5 pm
• CVS- S1, S2 heard  no thrills or murmurs
• Abdomen-  soft, non tender, no palpable masses
• Respiratory- NVBS heard
• Outside brain MRI showing- Acute lacunar infarcts ?

Provisional diagnosis- 

• Altered sensorium secondary to ? Post ictal confusion - ? Focal seizures with impaired awareness
• Acute CVA 
• AKI 
• Anemia under evaluation 
• K/c/o prostate caner (post TURP)
• K/c/o HTN
• Seizures secondary to CVA or ? brain Mets 

4/7/21-

Planning- 

• Tab levipill 500 mg po/ od
• 20 NS 75 ml / hr
• Inj. Optinuron 1 amp iv/od
• Tab Nicardia  20 mg po/bd
• Tab Ecospirin 75 mg

Investigations: 

 

serum electrolytes showed elevated sodium- 

    Random blood sugar showed hypoglycemia- 

     Liver function tests showed elevated ALP and total proteins- 

     Elevated serum creatinine-

     Elevated blood urea- 

    ABG showed decreased pCO2 and bicarb- 

5/7/21- 

ECG-

Treatment plan-

      Same as previous day.

6/7/21-

•      Patient fully recovered same medication was given
•      Patient discharged.
•      Advice on discharge- Oral fluids 2-3 l/day, Levipill 500mg po/bd, Nicarda retard 20mg po/bd, Ecosporin AV 75mg po/od

      Discharge summary :

     Date of discharge : 6/7/21

     Brought to hospital at 4:00pm on 4/7/21

     Chief complaint-

• Patient came to casualty in drowsy state since 3pm
• patient was in altered state from morning  
• C/o history of involuntary defecation 1 episode in the morning

    History of presenting illness-

• He was apparently asymptomatic 6 months back 
• He development hematuria 20 days after which they went to Gandhi hospital where he was diagnosed with prostate cancer (adenocarcinoma) for which a surgery (bilateral orchidectomy)  was done and then referred to MNJ hospital for further treatment. 
• He also had history of 1 episode of GTCS 6 months back with involuntary movements, lip bite, frothing from mouth, involuntary micturition which was treated  and patient was in confusion for 2 days.
• Since then he was on tab. Levipill 500mg po/bd
• At the same time he was admitted in hospital as he was diagnosed hyponatremia and was treated.
• Then he was referred to MNJH hospital and was diagnosed for prostate cancer ( Adenocarcinoma) . For pain he was given morphine ½ tablet 2 hourly and 1 tablet at night. 
• Today after taking the pill patient was unconscious from morning and was drowsy from 3 pm   
• History of involuntary defecation in the morning

   Family history- 

• Patients brother and 2 children suffer from mental disability

·    Examination- Objectively-

Mild Pallor

• No Icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy
• PR 88 BPM
• RR 22 cpm
• BP- 110/60 mmHg
• GRBS- 110
• SpO2- 87% at room air
• CNS- Drowsy arousable, no focal deficit
• Power- 

                   UL      LL

           Lt    4+/5    4+/5

           Rt    4+/5    4+/5

• Patient became conscious around 5 pm
• CVS- S1 S2 heard  no thrills or murmurs
• Abdomen-  soft, non tender, no palpable masses
• Respiratory- NVBS heard
• Outside brain MRI showing- Acute lacunar infarcts ?

Provisional diagnosis- 

• Altered sensorium secondary to ? Post ictal confusion - ? Focal seizures with impaired awareness
• Acute CVA 
• AKI 
• Anemia under evaluation 
• K/c/o prostate caner (post TURP)
• K/c/o HTN
• Seizures secondary to CVA or ? brain Mets 

Planning- 

• Tab levipill 500 mg po/ od
• 20 NS 75 ml / hr
• Inj. Optinuron 1 amp iv/od
• Tab Nicardia  20 mg po/bd
• Tab Ecospirin 75 mg

Plan was followed for three days, patient made full recovery and was discharged. 

I would like to thank Dr. Rakesh sir (HOD, General Medicine) for given me this opportunity, And Dr. Vinay sir (PG) and Dr. Kusuma ma'am for guiding me throughout the whole process of making an elog !