A 60 year old female with seizures

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 

60YR OLD FEMALE PATIENT, RESIDENT OF RAMANAPET,FARMER BY OCCUPATION, CAME TO THE OPD,WITH THE CHIEF COMPLAINTS OF : 

C/O Involuntary movements of Lt UL and LL ( first episode ) , associated with frothing ,Uprolling of eyes ,Tongue Bite ,Post Ictal Confusion present for 10 minutes .

No seizure activity at presentation but H/O two episodes of seizures occured at their home place and at their local Hospital ( at Ramanapet).

 Fever ,which is Sudden in onset and intermittent type  since 2 days associated with chills ,rigors  and head ache , blurring of vision 

Neck pain- dragging type ,diffuse ,present since 2days 

H/O fall from bike 2years ago , led to mild abrasions over body and head  and associated with fracture of LT wrist joint (as she fell over left side -one side) .

No H/O Cold ,Cough , loss of appetite, Diurnal Variation , Burning Micturition 

PAST HISTORY: 

Not a K/C/O HTN, DM II , Epilepsy,Asthma ,TB , CAD ,CVD ,Thyroid 

PERSONAL HISTORY : 

Appetite -Normal 

Diet - Mixed 

Sleep - adequate

Bowel and bladder movements -Regular 

Addictions: Occasional alcoholic ( once every 3days - she consumes 90ml of alcohol )

Betel Nut chewing - Daily for 5-6 times 

Allergies : No allergies 

GENERAL EXAMINATION: 

Patient is conscious ,coherent , cooperative, Moderately Built and Moderately Nourished.

Temp: Afebrile 

BP : 130 / 90 mmHg 

PR : 87bpm 

RR : 20cpm 

SPO2 : 96 %

GRBS : 155 mg/dl 

Pallor : absent 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent 

SYSTEMIC EXAMINATION: 

CNS : HMF +  

                  RT                    LT 

Tone : UL : N                    N

             LL : N                    N

Power : UL -5/5                5/5

               LL- 5/5                 5/5 

Reflexes : biceps: 2+            2+

                Triceps : 2+           2+

                   Knee:   2+            2+

                   Ankle : 1+            1+

             Supinator : 1+           1+

              Babinsky : plantar       plantar 

                                  Flexion        flexion 

CVS  :   S1 S2 + ,no murmurs 

RS :  BAE Present 

P/A : Soft and Non tender 

Meningeal signs like : neck stiffness , kerning sign,brudzinsky sign are negative 

INVESTIGATIONS:

j

MRI BRAIN  REPORT: 

-Acute Infarcts in Right  Precentral Gyrus ,Pre motor area ,middle frontal gyrus ,centrum semi ovale ,Corona Radiata 

- Mild  diffuse  Cerebral atrophy 

PROVISIONAL DIAGNOSIS: 

FOCAL SEIZURES WITH  SECONDARY GENERALISATION 

MANAGEMENT: 

Inj . Levipil 500mg IV /BD  in  100 ml NS

 Tab . Ecospirin gold AV 75/10 mg PO /OD /HS 

Tab . Dolo 650 mg PO/ TID 

Inj PCM 1gm IV / SOS ( if temp > 101°F ) 

Temperature Monitoring 4th Hourly 

Vitals Monitoring 6th hourly 

SOAP NOTES: 

S

No fever spikes 

Giddiness + 

Tongue Numbness + 

O 

Patient is Conscious ,Coherent , Cooperative

Temp : Afebrile 

BP : 110 /80 mmHg 

PR : 76bpm 

RR : 18cpm 

GRBS : 

2AM - 135 mg/dl 

8AM - 123 mg/dl 

CVS : S1S2 + 

RS : BAE + 

CNS: NAD 

SPO2 : 99%

I /O : 1000/300 ml 

A 

FOCAL SEIZURES WITH 2° GENERALISATION 

(HYPOKALEMIA) 

P 

IV Fluid 1. NS with OPTINEURON 1amp IV /OD 

Inj Levipil 500mg IV /BD 

Inj KCL 2 amp in 500 ml NS IV/STAT Over 5 hours 

T . Ecospirin AV 75/10 mg PO/OD/HS 

T. Dolo 650 mg PO /SOS 

Temp Monitoring 4th hrly 

Vitals monitoring 6th hrly

DISCUSSION:

FMR = body fat mass (kg) divided by muscle mass (kg)

In men, the risk of Metabolic Syndrome was 2.9-fold higher in the high-FMR group than in the low-FMR group; in women, it was 9.5-fold higher.

A population-based study revealed that the cutoff values of FMR for identifying MS were 0.336 in men and 0.555 in women

The fat-to-muscle ratio is independently and positively associated with metabolic disorders in T2DM. FMR may serve as an optimal method for screening T2DM patients coupled with a high risk of abnormal metabolism, especially in females 

Excessive adipose tissue was identified to be accompanied by decreased skeletal muscle quantity, known as SARCOPENIC OBESITY. This combined phenomenon was more closely related to insulin resistance, especially in T2DM patients. Thus, a decline in skeletal muscle mass combined with an increase in body fat may cause a dual metabolic burden, resulting in a higher probability of developing severe metabolic disorders.

Skeletal muscle is one of the main sites of glucose uptake and utilization, decreased muscle mass increases insulin resistance, thereby increasing the risk of T2DM and MS.

Lunar DXA visceral fat could be used to measure visceral fat with results comparable to CT(gold std), relatively rapid, inexpensive with minimal radiation dosage.

https://dmsjournal.biomedcentral.com/articles/10.1186/s13098-021-00748-y

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698596/

As above method is not approachable to large patients 

MUAC is a novel indicator

Pathophysiology of visceral mass on atherosclerosis 

Yes sir

Fat mass increases with muscle loss in two potential ways.

 The most direct way is the storage of the energy contained in atrophying muscle as fat. Skeletal muscle is estimated to contain 1.8 kcal/gram of muscle. When muscle atrophies only 1.1 kcal/g of energy is released. The energy contained in the atrophying muscle tissue remains in the body unless negative energy balance ensues. 

Another factor affecting age-related loss of muscle and weight gain is a decline in insulin sensitivity. Fat cells and immune cells create a condition of low-grade inflammation. This unfavorable adipokine/cytokine profile further decreases insulin sensitivity, which amplifies inflammation and oxidative stress, but also contributes to ectopic fat disposition. Oxidative stress-derived inflammation may be a major mechanism in the pathogenesis and progression of obesity-related metabolic diseases and sarcopenia

Sarcopenia can also induce gains in fat through reductions in physical activity. Sarcopenia is known to impair the ability to perform physical activity 

https://www.hindawi.com/journals/jobe/2019/8031705/

https://www.e-enm.org/m/journal/view.php?number=2008

Study establishing higher prevalence of metS in sarcopenics than in non sarcopenics

 https://www.liebertpub.com/doi/10.1089/met.2019.0059

*4. How is visceral fat linked to insulin resistance?*

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4625546/

Visceral adipocytes show overexpression of RBP-4 (a.k.a adipokines). This decreases expression of GLUT-4 transporter to cell surface, decreasing intake of glucose, causing insulin resistance.

 CREDITS : DR.SUPRIYA (2k17 roll no :63