28th February, 2023
MEDICAL
REPORT
O. K, 39YEARS, FEMALE
WCA/6056/2023
Diagnosis:
·
Hypertensive
emergency
·
Hypertensive
encephalopathy
Background
Information (28/02/2023- 12noon)
She
is a known but poorly controlled hypertensive. While attending to her daughter’s
checkup and waiting in the reception for her turn, attention was drawn to her
sudden onset of tight focal seizures, impairment of consciousness and collapse
as the seizure progressed to generalized tonic clonic semiology which lasted
for about 3-5mins. Seizure was however aborted with i.m diazepam 10mg after
which an I.V line was secured and further 4mg midazolam given about an hour
later as the focal seizure and restlessness continued. iv normal salinecontinued,airway
cleared of all secretions in line with BLS and oxygen administered via face
mask at 5l/min.During this episode, BP was 200/120mmHg. RBS-7.4mmol/l. Further
probe into the past medical history revealed similar episodes in the past.
Samples
were taken for EUCR and FBC which the result were all within the normal range.
NG Tube was passed and tabsamlodipine 10mg and valsartan 160mg was given while
cardiology consult was arranged,
Urgent Brain CT scan
done 28/02/2023 (1:30pm)- below shows no evidence of
infarction or intracerebral hemorrhage. There was also ample evidence of good
corticomedullary differentiation. There was therefore no immediate need for any
surgical intervention
Thereafter she was admitted to the critical care unit and multimodality monitoring commenced including- hourly GCS, pupils, Limbs MRS, vital signs, spo2, fluid balance.
Cardiology Review
28/02/2023 (5pm)
Known
hypertensive with? poor BP control due to poor history of adherence. Said to
have had a total seizure earlier today.Nil Head trauma.Nil weakness of any side
CT
scan of brain was normal. BP- 176/100mmHg.
Plan: Recommence Exforge 10/160mg O.D
To continue above monitoring in the
ICU and to be reviewed in 24hrs.
Neurology
review at about same time equally agreed with the above lines of management
Update 01/03/2023 (3am)
Attention
drawn to patient whose BP was noticed to be elevated 197/102mmHg.
RBS:
16.9mmol/l
Tabs Nifedipne 20mg stat
3:30AM
BP
after 30mins: 185/101mmHg
Plan:
Tabs valsartan 160mg stat
For
cardiologist review later today
4:30am
BP
was noted be uncontrollable on above interventions, she suffered another GTC,
desaturated and required urgent endotracheal intubation. Nospontaneous
respiratory effort has been observed since then as she has remained on
mechanical ventilatory support
PR-
125bpm.BP- 198/98mmhgSp02: 91% on ventilator support
8:30 am
BP
was noticed drop top 80/50 and required inotropic support to prop it up to
130/80mmHg
Plan:
Continue neuro vital monitoring.
Family
was summoned and detailed briefing of above developments and interventions thus
far explained to their basic understanding especially the fact that she now
required both cardiovascular and respiratory support to maintain vital signs.
The prognostic implications of these developments were also explained to them
However they advised the support continues while we review in the next 24 hrs.
02/03/2023 (9:00am)
Neurological
condition remained same – GCS 2T, Pupils dilated and fixed, no spontaneous
respiratory efforts and complete dependence on cardio-respiratory support above
with no evidence of restoration of brain stem reflexes. Clinical diagnosis of
brain stem death was made.
Again,
family was summoned for a meeting as planned and briefed accordingly. They
still decided and advised we maintain status quo support and hoping for a turn
around.
1:35pm- Family
requests for medical report a transfer to Nizamiye Hospital to continue care
there. Meanwhile her condition remains same.
Medical
report is updated to the hour and for transit, an ambulance with mobile
ventilator and requisite critical care staff is required for continued care and
safety is advised.
Kindly
revert for further clarifications if need be.
Sincerely yours,
Dr.
Halima Ibrahim
For
Team Wellington Clinics