A CASE WITH FOCAL SEIZURES SECONDARY TO HYPERGLYCEMIA


CHIEF COMPLAINTS:
A 65Y old Male came with
C/o Involuntary movements of Left UL since 5days
Dribbling of urine since 2days


HOPI:
pt. was apparently asymptomatic 5days ago, the he had involuntary movements of left upper limb which was sudden in onset, each episode lasting for 15-30 seconds.
Slurring of speech present +
Urinary incontinence since 2days
No h/o loss of consciousness/ head trauma
No h/o speech abnormality
No h/o projectile vomitings, headache or blurring vision
No h/o chest pain/ palpitations
No h/o SOB, pedal edema and bowel disturbances

{The pt. was previously admitted in hospital on 11/7/2021 with 
C/o weakness of B/L upper and lower limbs
Involuntary contraction of hip muscles(twitching) and
Generalised weakness since 15days
Deviation of mouth to right. +

       (20days prior to the admission, pt. was taken to near by hospital (Nalgonda) for B/L weakness of UL & LL , where he was diagnosed with uncontrolled sugars and discharged after 3days)

MRI done during his 1st course of admission:
- T2/FLAIR SUBCORTICAL WHITEMATEER HYPOINTENSITY IN RIGHT PARIETO OCCIPITAL TEMPORAL LOBES
>D/D HYPERGLYCEMIA INDUCED SEIZURES (NON-KETOTIC HYPERGLYCEMIA)--MOST LIKELY
>ISCHEMIA--LESS LIKELY
>MENINGOENCHEPALITIS--LESS LIKELY
- SUBTLE HYPERINTENSITY IN THE RIGHT MEDIAL TEMPORAL LOBE -- POST ICTAL CHANGES
- FEW MICRO BLEEDS (< 5 IN NUMBER) IN BILATERAL CEREBRAL HEMISPHERES 

USG - ABDOMEN:
- RIGHT KIDNEY GRADE 1 RPD
- LEFT KIDNEY GRADE 2 RPD

   He was diagnosed with 
DYSTONIA SECONDARY TO METABOLIC CAUSE(RESOLVED)
K/C/O TYPE 2 DIABETIC WITH UNCONTROLED SUGARS, for which treatment with INJ. HAI &NPH acc. to GRBS, KCL& SYP. POTCHLOR( for K+ correction due to low levels of K+ : 3.0mEq/L), INJ. LEVIPIL, INJ. PHENARGAN, INJ. CEFTRIAXONE and other nutritional supplements like INJ. OPTINEURON was given.}

{Pt. had an another history of admission in hospital on 13/03/2022 with
C/o loss of speech and unresponsiveness since 8am
Weakness of left UL and LL
Deviation of mouth to right. +

On CNS examination:
PATIENT IS CONSCIOUS, COMPREHENSIVE +
NO SPEECH/ PUPILS - B/L NSRL
NOT OBEYING ORAL COMMANDS, TONGUE BITE +,DEVIATION OF MOUTH TO RIGHT
                     R  L
POWER: UL 4  3
               LL 4 3 
TONE AND REFLEXES:
BICEPS 2+ 2+ ; TRICEPS 2+ 2+ ; SUPINATOR - -
KNEE - - ;ANKLE 2+ 2+ ;PLANTAR MUTE MUTE

MRI was done on 13/03/2022:
Showed SUB- ACUTE TO CHRONIC INFARCT IN RT. PARIETAL AND OCCIPITAL LOBES OF BRAIN

He was diagnosed with 
   ? SEIZURES SECONDARY TO ? OLD CVA WITH TODD’S PALSY (RESOLVED), and treated with INJ. LEVIPIL, INJ. OPTINEURON, T. ECOSPIRIN, T. CLOPITAB , T. ATORVAS }

PAST HISTORY:

-k/c/o HTN AND DM since 3 yrs (on regular medication)

-OLD CVA ,left hemiparesis 1yr back on 14/7/21, resolved on treatment

-BALANITIS WITH B/L HYDROCELE (RT. > LT.)

No h/o Asthma, TB, CAD 


Personal history :

Diet -mixed,

sleep - adequate, 

appetite - normal., 

bowel and bladder- urinary incontinence +


GENERAL EXAMINATION:

Patient is c/c/c, moderately built and nourished. 

No pallor, icterus, cysnosis, clubbing, lymphadenopathy or edema 




(Vitals @ Admission:)

Temp - Afebrile

PR-108bpm

BP - 140/90 mmHg

Spo2 - 99%.

RR - 18 CPM

GRBS-HIGH


SYSTEMIC EXAMINATION:

CVS - S1 S2 +

RS - BAE +, CLEAR, 

         NVBS. 

P/A - soft, non tender, no organomegaly. 

CNS: pt. is c/c/c

Tone: 

R-UL-N, L-UL- decreased

R- LL- N, L- LL- N

Power:

R-UL:4/5

L-UL:3/5

R-LL:4/5

L-LL:4/5

Reflexes:   R. , L.  

B:               +. , +

T:               +. , +

S:               +. , +

K:               +. , +

A:                - , -

P:             Mute,Mute

Sensory system: NAD

Cranial NS:.  intact


REFLEXES OF BOTH UL AND LL


INVESTIGATIONS-

17/04/22:

Serum calcium- 9.9 mg/dl

Serum electrolytes- Na/k/cl- 131/4.8/97

18/04/22:

RBS- 765 

ESR - 20 MM/1 ST HR

Urine for ketone bodies- NEGATIVE

CUE: ALB- TRACE 

          PUS CELLS 3-4

          SUGAR +++

Hemogram - Hb- 12.6 gm /dl

                       Tlc- 7000 cells/cumm

                        Plt-1.76 lakhs/cumm 

Blood urea -53 mg/dl

Phosphorus- 3.2 mg/dl

Serum creatinine- 1.98 mg/dl

Serum magnesium-2.1 mg/dl

Uric acid - 3.2 mg%

LFT:

TB- 1.44; DB- 0.48; AST- 14 ; ALT-13; ALP- 307; TP-7.3; A/G RATIO -1.30

19/04/22:

Hemogram- Hb- 12.7 gm /dl

                       Tlc- 7200 cells/cumm

                        Plt-1.73 lakhs/cumm 

PLBS- 343 mg/dl

Serum electrolytes- Na/k/cl- 140/3.5/92

21/04/22:

Blood urea- 38mg/dl

Serum creatinine- 2mg/dl

Serum electrolytes:

Na/K/Cl- 137/3.7/98

22-04-22:

FBS-125

PLBS-199

serum creatinine-1.6

serum electrolytes- Na/k/cl-139/3/102


ECG:


CHEST X-RAY:


DIAGNOSIS: FOCAL SEIZURES SECONDARY TO HYPERGLYCAEMIA, OLD CVA, OLD SEIZURES 


TREATMENT:

1.INJ. NPH S/C BD 

2.INJ.HAI S/C TID according to grbs 

3.1.IVF NS IV @75 ML/HR

4.INJ.EPTOIN 100 MG IN 5 ML NS IV/SLOW

5.TAB. LEVIPIL 500 MG PO/ BD

6.INJ. CEFTRIAXONE 1 GM BD IV

7.BP- MONITORING 4 TH HRLY 

8, TAB. ECOSPRIN AV 75/10 OD P/O H/S

9.TAB.PANTOP 40 MG O/D P/O

10GRBS 7 POINT PROFILE

11.I/O CHARTING


SOAP NOTES:

20-04-22 ( AMC)


S - C/O Urinray incontinence since 3 days ,?B/L Hydrocoele and balanitis


O - 

Pt - c/c/c

Temp - 102 F

PR- 78bpm

BP -  110/80mmHg

Spo2 - 99%.

RR -18 CPM

Systemic Examination :

CVS - S1 S2 +

RS - BAE +

P/A - soft, non tender, no organomegaly. 

CNS - NAD


A:

FOCAL SEIZURES SECONDARY TO HYPERGLYCEMIA; OLD CVA ,OLD SEIZURES


P:

1.INJ. NPH S/C BD 

2.INJ.HAI S/C TID according to grbs 

3.1.IVF NS  (0.9%) @75 ML/HR

4.INJ.EPTOIN 100 MG IN 5 ML NS IV/SLOW

5.TAB. LEVIPIL 500 MG PO/ BD

6.TAB.CEFTRIAXONE 1 GM BD IV

7.BP- MONITORING 4 TH HRLY 

8, TAB. ECOSPRIN AV 75/10 OD P/O H/S

9.TAB.PANTOP 40 MG O/D P/O

10GRBS HRLY 

11.I/O CHARTING


GRBS TRENDS :

19-04-22

10 AM - 569 MG /DL

12:00 AM-GRBS -362 mg/dL12ml/hr

12:30AM  -314 mg/dl 10 ml/ hr

2:00 AM -181 mg/dl 2 ml/hr

4AM - 178mg/dL 2ml/hr

5AM -135mg/dL 1ml/hr 

6AM- 200mg/dL 2ml/hr

7AM- 139mg/dL 1ml /hr

20-04-22

10:00Am- 356 mg/dl

12:00am- 386mg/dl inj.NPH 4 units given

2.00 am- 358mg/dl

4:00 am- 373mg/dl

6:00 am -398mg/dl

8:00am- 354mg/d l inj.HAI 12+ inj.NPH 10 units given


SOAP NOTES:

21-04-22 ( AMC)


S - No fresh complaints 

Rt. Sided Hydrocele with balanitis


O - 

Pt - c/c/c

Temp - 102 F

PR- 87bpm

BP -  120/80mmHg

Spo2 - 98%.

RR -18 CPM

Systemic Examination :

CVS - S1 S2 +

RS - BAE +, lungs clear

P/A - soft, non tender, no organomegaly. 


A:

FOCAL SEIZURES SECONDARY TO HYPERGLYCEMIA; OLD C/O SEIZURES 1YEAR BACK, H/O CVA

K/C/O DM-2 ON MEDICATION


P:

1.INJ. NPH S/C BD 

2.INJ.HAI S/C TID according to grbs 

3.1.IVF NS  IV  @75 ML/HR

4.INJ.EPTOIN 100 MG IN 5 ML NS IV/SLOW

5.TAB. LEVIPIL 500 MG PO/ BD

6.INJ. CEFTRIAXONE 1 GM BD IV

7.BP- MONITORING 4 TH HRLY 

8, TAB. ECOSPRIN AV 75/10 OD P/O H/S

9.TAB.PANTOP 40 MG O/D P/O

10GRBS 7 POINT PROFILE

11.I/O CHARTING


GRBS TRENDS :

21-04-22

10:00Am- 544 mg/dl 

11:00 am- 600 mg/dl inj. HAI 6units given 

2.00 pm- 561mg/dl

6:00 pm -342mg/dl

8:00pm- 106mg/dl inj.HAI 6units given

10pm- 294mg/dl

2am- 194mg/dl


SOAP NOTES:

23-04-22 ( AMC)


S -NO FRESH COMPLAINTS


O - 

Pt - c/c/c

Temp - 102 F

PR- 84bpm

BP -  120/70mmHg

Spo2 - 99%.

RR -18 CPM

Systemic Examination :

CVS - S1 S2 +

RS - BAE +

P/A - soft, non tender, no organomegaly. 

CNS - NAD


A:

FOCAL SEIZURES SECONDARY TO HYPERGLYCEMIA; OLD CVA ,OLD SEIZURES


P:

1.INJ. NPH S/C BD 

2.INJ.HAI S/C TID according to grbs 

3.1.IVF NS  (0.9%) @75 ML/HR

4.INJ.EPTOIN 100 MG IN 5 ML NS IV/SLOW

5.TAB. LEVIPIL 500 MG PO/ BD

6.TAB.CEFTRIAXONE 1 GM BD IV

7.BP- MONITORING 4 TH HRLY 

8, TAB. ECOSPRIN AV 75/10 OD P/O H/S

9.TAB.PANTOP 40 MG O/D P/O

10GRBS 7 POINT PROFILE

11. TAB.FRISIUM 10 mg po /OD if seizures continued

12.TAB.RENERVE P H/S OD 

11.I/O CHARTING


GRBS TRENDS :

22-04-22

10:00 AM -182 MG/DL

2: 00pm-105mg/dl  8 UNITS HAI given

4 00pm-233mg/dl

5:00pm -188mg/dl

8:00PM- 116 mg/dl NPH 10 + HAI10 given

10 :00 PM- 285mg/dl

23-04-22

12:00 AM- 223mg/dl

6 :00am-86mg/dl  NPH10+ HAI 10 given



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