30 year old female with seizures under evaluation with fever with thrombocytopenia

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 A 30 year old female came to casuality with the chief complaints of  

Fever since 10 days  

Yesterday she had an episode of Involuntary movements of bilateral upper limb and lower limb  since yesterday evening 


HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic  10 days back then she developed fever which was insidious in onset , gradually progressive ,not associated with chills and rigour subsided on medication she was treated conservatively and then on further investigations she was diagnosed with NS1 Antigen positive and was on conservative management since then .

Yesterday she had an episode of  involuntary movements of B/l UL and LL associated with uprolling of eyes woth drooling of saliva lasting for 2 mins , no involluntary micturition/defecation/tongue bite 

No post ictal confusion

No complaints of palpitations, shortness of breath , orthopnea , burning micturition 



PAST HISTORY: 

H/o seizures 5 years back in her first pregnancy and wasn’t on any medications 

N/k/c/o HTN , DM , epilepsy , asthma , tb 


O/E : 

Patient is consious , coherent and cooperative 

Temp:afebrile

Bp:110/80 mm hg

PR:84 bpm

RR: 20/ min

Cvs :S1 S2 heard

Rs: BAE  +

Spo2:94%



PROVISIONAL DIAGNOSIS : 

Seizures under evaluation with fever with thrombocytopenia 


INVESTIGATIONS:

















TREATMENT:

1.Inj levipill 1 gm in 100 ml ns / iv stat

2.Inj pan 40mg iv stat

3.IVF ns and rl @75 ml / hr  with 1 amp of  optneuron iv /OD

4.Inj zofer 4 mg iv / sos 

5.Inj neomol 100 ml ( if temp is > 101.1 F) 

6.Tab PCM 500 mg /po/tid 

7.Tab levipil 500mg / po/bd 

8.Inj lorazepam 2cc /iv /sos 

9.W/f bleeding manifestation

10.W/f any seizure activity 


SOAP NOTES 

Day 2

AMC CASE


 

SUBJECTIVE - 

No fever spikes


O:- 

Patient is conscious , coherent , cooperative 

- oriented to time , place , person 

Temp:- afebrile

PR:- 85bpm

BP:- 130/90mm hg

RR:- 18cpm

SPO2 :- 99% @RA

CVS:- S1S2 + , No murmurs

RS:- NVBS + , No crepts 

P/A :- Soft , non tender

          Bowel sounds heard


ASSESSMENT -


Seizures under evaluation with fever with thrombocytopenia 




PLAN OF CARE-


1. IVF 1 NS ,1 RL @ 75ML/HR WITH 1 AMP OF OPTINEURON IV/OD

2. INJ.PANTOP 40 MG IV/BD

3. INJ.ZOFER 4 MG PO/SOS

4.INJ.NEOMAL 100 ML(IF TEMP > 101.1F)

5.TAB.PCM 500 MG PO/TID

6. TAB.LEVIPIL 500 MG PO/BD

7. INJ.LORAZEPAM 2cc /IV/SOS

8. W/F BLEEDING MANIFESTATIONS 

9. W/F ANY SEIZURE ACTIVITY


SOAP NOTES 

WARD DAY 3


 

SUBJECTIVE - 

No fever spikes


O:- 

Patient is conscious , coherent , cooperative 

- oriented to time , place , person 

Temp:- afebrile

PR:- 82bpm

BP:- 120/90mm hg

RR:- 18cpm

SPO2 :- 99% @RA

CVS:- S1S2 + , No murmurs

RS:- NVBS + , No crepts 

P/A :- Soft , non tender

          Bowel sounds heard


ASSESSMENT -


Seizures under evaluation with fever with thrombocytopenia 




PLAN OF CARE-


1. IVF 1 NS ,1 RL @ 75ML/HR WITH 1 AMP OF OPTINEURON IV/OD

2. INJ.PANTOP 40 MG IV/BD

3. INJ.ZOFER 4 MG PO/SOS

4.INJ.NEOMAL 100 ML(IF TEMP > 101.1F)

5.TAB.PCM 500 MG PO/TID

6. TAB.LEVIPIL 500 MG PO/BD

7. INJ.LORAZEPAM 2cc /IV/SOS

8. W/F BLEEDING MANIFESTATIONS 

9. W/F ANY SEIZURE ACTIVITY


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