OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: TAN,NELLY Hospital #: 1709058 Age/Sex: 67/F Address: 1845 M Guazon St. Paco Manila Date of admission: April 12,2007 Admitting Diagnosis: Status Epilepticus Complex Partial Seizure Probably 2 to 1.Structural 2.Metabolic DM type2, PTB V Residents in charge: Dr. Drs. Magbiray, Torres, Filio, and Indon Intern-in-Chage: Maganda Clerk-in-Charge: Navarro/Ponelas/Reyes
24 hr history
This is a case of a 67 year-old female who was admitted due to seizure episodes History of Present Illness Patient had 2 previous hx of severe seizure episodes (December 2006 & February 2007). Patient had no medications for seizure episodes. Patient was apparently well until… 1 hour PTA, patient had facial muscle twitching, stiffening of upper extremities. Patient became unresponsive to verbal stimuli. There was also upward rolling of the eyeballs, drooling of saliva , hence patient sought consult and was subsequently admitted. Past Medical History She was diagnosed to have DM type 2 maintained on insulin 20 u SQ at HS, Metformin 500mg tab TID, Gliclazide 800 mg tab TID, No HPN, No BA, No Hx of Cancer. (+) PTB- treated for 1 year with poor compliance INH, Rifampicin 3 tabs OD. Family History Patient denied heredofamilial disease. Personal and Social History Nonsmoker and non-alcoholic beverage drinker Review of Systems General: (-) fever, (-) anorexia, (-) weight loss HEENT: (-) dizziness, (-) blurring of vision Respiratory: (-) colds, (-) hemoptysis Cardiac: (-) PND Gastrointestinal: (-) abdominal pain, (-) LBM Neurologic: (-) seizure, (-) loss of consciousness Urinary: no dysuria, no oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Heumatology: no joint pains Physical Examination: Asleep, stretcher borne Vital Signs: BP: 110/80 HR: 60 RR: 20 Temp: 37.0oC HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, no distended neckm veins CHEST AND LUNGS: symmetrical chest expansion, no retraction, clear breath sounds HEART: adynamic precordium, normal rate, PMI 5th ICS LMCL,regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non-tender EXTREMITIES: grossly normal, with full and equal pulses Assessment: Status Epilepticus
Complex Partial Seizure Probably 2 to 1.Structural 2.Metabolic DM type2, PTB V
PLAN: Patient was admitted to the service of Drs. Magbiray, Torres, Filio, and Indon. Consent for admission was secured. Patient was put on NPO while hooked on PNSS x 12 . Diagnostic procedure requested were:BUN,crea, Na, K, Ca, Mg, CPK MM, ABGs,RBS, 12 L ECG, CXR AP, CBC c PC, SGPT,SGOT, UA, FBS,HDL,LDL,TG,TV,BUA, HBA1C, EEG, Cranial Ct scan, SPUTUM AFB x3 . Medications prescribed were: Regular Insulin 5 u SQ for CBG > 250 mg/dL, Diazepam 50 mg/2 ml amp, IV PRN for frank seizures, Sucralfate 1 gram every 6 hours /NGT. O2 support via nasal canulla. st On the 1 hospital day, patient is maintained on NGT. Start OF feeding at 1800 kcal /day in 3 divided doses. Still IVF to PNSS 1L + 40 meqs KCL x 6. FF up official CT scan results. Started with Ciprofloxacin 500mg 1 tab BID/NGT, K citrate 2 tabs TID/NGT. VS, NVS q1,CBG q4,
o2 at 10 lpm/1m. Patient’s CBG was 300mg/dl and was given regular insulin 5 u SQ then prn >250mg/dl. Patient was intubated and maintained on NPO., started on mannitol, hooked to mechanical ventilator support. Patient was referred back to svc consultant. Ancillary proced ures delayed. PWI: Status Epilepticus 2 to Complex Partial Seizure prob metabolic in origin. Check for serum urine ketone. Endo referral was suggested. Patient was requested for serum ketone and urine ketone.