H/o ? seizure activity yesterday night(not witnessed by standers), his wife got a call today morning saying he is lying on the side a road and brought to casualty.
history of recurrents eizures activity since childhood, first episode occured when he was 5yrs of age when he had fever followed by a seizure eposode. he was on medication for 3-4 yrs and discontinued.
h/o alcohol abuse since 20 yrs, started consuming after his sister's death.
he got married thirteen yrs back 2yrs after which he had another episode of seizure(lTonic) at that time alcohol consumption was 90ml/day.
Since 20days he consumed alcohol at 11pm and had seizures(tonic, staring and frothing) 10am the following morning.
His consumption increased over these 20days and decreased food consumption,
last seizure activity was 4 days back.
last binge of alcohol consumption was yesterday afternoon.
last seizure activity was apparently last night (not withnessed by wife)
his is not a k/c/o HTN, DM, TB, BA, CVA, CAD
no significant past medical a d surgical history
no significant family history
On presentation
his was afebrile to touch
PR- 58bpm
BP- 110/50
SPO2- 99%
GRBS- 22mg/dl
CVS- S1 S2+
RS- BAE+ NVBS+
PA- soft, non tender
SOAP notes
ICU bed 4
S- pt is drowsy
No fever spikes
No seizures episode
objective-
temp- Afebrile
PR- 72 bpm
BP- 150/110mm HG
SPO2- 99%
GRBS- 112 mg/dl
CVS- S1 S2+
RS- BAE+ NVBS+
PA- soft, non tender
CNS- Pt was drowsy but arousable
Orientation-
Reflexes- B. T. K. A. P
R.+3 +3 +3 +3 extension
L +3 +3 +3 +3 flexion
A- ? alcohol withdrawal seizures
Plan- propped up position
ryles tube feeding- free water 4th hourly amd milk+ protein powder 6th hrly
IVF NS, RL 100ml/hr
Inj thiamine 1amp in 100ml NS TID
Inj phynitoin 100 in 100ml.NS IV TID
inj pan 40 mg iv od bbf
inj lorazepam 2cc iv sos
nebulization duolin 8th hrly
nebulization budecort 10th hrly
SOAP NOTES
ICU BED 4
40YR OLD MALE
S:
patient is drowsy
No fever spikes
No seizural episodes.
O:
Temp:99.5f
PR: 78bpm
Bp: 160/100 mmHg
SPO2: 99%
GRBS: 144mg/dl
CVS: S1S2+
RS: BAE+, NVBS +
PA: soft,non tender
Patient is drowsy but arousable, not oriented to time,place,person.
A:
?Alcohol withdrawal seizures
P:
Propped up position
Rules tube feed- free water 4th hrly and milk + protein powder 6th hrly .
IVF : NS,RL 100ml/hr.
Inj.thiamine 1amp in 100ml NS TID
Inj pan 40mg i.v/OD/ BBF
Inj . lorazepam 2cc i.v sos
Soap notes
ICU bed 4
paient is drowsy
No fever spikes
No seizural episodes
Objective
E4 V5 M6
Hallucinating and no sleep
temp- Afebrile PR- 76 bpm
BP 120/80mm HG
SPO2-99%
GRBS- 106 mg/dl
CVS-S1 S2+
RS-BAE+ NVBS+
PA- soft, non tender
Patient is drowsy,but arousable, not oriented to time,place,person
A- ? alcohol withdrawal seizures
Plan-propped up position ryles tube feeding- free water 4th hourly amd milk+ protein powder 6th hrly
IVF NS, RL 100ml/hr
Inj thiamine 1amp in 100ml NS BD Inj phynitoin 100 in 100ml.NS IV BD
inj pan 40 mg iv od bbf
inj lorazepam 2cc iv sos
Syp potklor 15ml po BD in a glass of water
Tab amlong 5mg po od
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