Time point

Clinical features

Investigations

Managements

At ED presentation

· GCS 3/15

· Vitals: Tachycardia, otherwise normal vital signs

· Nonreactive pupils

· Stiff jaw and tongue biting

· Chest: Crepitation over the left lung

· Cardiac: Normal S1, S2 no added sound

· Abdomen is soft and lax

· VBG: (ph: 7.25, Na 109 mmol/L, K 3.5 mmol/L, lactate 6.5 mmol/L, pCO₂: 48. HCO₃ 18 mmol/L)

· Random Blood Glucose: 7.2 mmol/L

· Patient was connected to monitor

· IV lines were established

10 minutes after ED presentation

· Seizure attack (tonic-clonic) non-reactive pupil, jaw stiffness

· Labs sent: Complete blood count (CBC), Renal function panel, electrolytes

· Midazolam 2 mg IV bolus

· 100 ml of 4.8% sodium bicarbonate IV bolus

25 minutes after ED presentation

· Clinical seizure was continued

· Patient face was puffy

· Repeated dose of 100 ml of 4.8% sodium bicarbonate IV bolus

35 minutes after ED presentation

· Subclinical seizure, persistent non-reactive pupil, jaw stiffness

VBG: (ph: 7.25, Na 112 mmol/L, K 3.5 mmol/L, lactate 6.9 mmol/L, HCO₃ 17.2 mmol/L)

· Started phenytoin 20 mg/kg IV

45 minutes after ED presentation

· Continued subclinical seizure

VBG: (ph: 7.19, Na 113 mmol/L, K 2.9 mmol/L, lactate 7.9 mmol/L, HCO₃ 16.5 mmol/L)

· 3% hypertonic saline 100 ml arrived from the pharmacy and infused over 20 minutes

1 hour and 5 minutes after ED presentation

· GCS 7/15

· Pupils were reactive to the light

VBG: (ph: 7.37, Na 116 mmol/L, K 2.6 mmol/L, lactate incalculable, HCO₃ 22 mmol/L)

· Monitoring was continued

2 hour after ED presentation until admission

· Desaturation on room air, fluctuating O₂ saturation (75-87%)

Chest X-ray: Multifocal airspace opacity in right lung

CT brain: Unremarkable

The presentation labs resulted:

CBC: (WBCs 19.9 10^*3/uL, absolute neutrophils 17.5 10^*3/uL, RBCs 3.58 10^*6/uL, hemoglobin 11.3 g/dl, platelet 210 10^*3/uL)

Renal function test: (Na: 110 mmol/L, k: 3.1 mmol/L, corrected calcium 1.88 mmol/L, phosphorus 0.42 mmol/L, magnesium 0.45 mmol/L, creatinine 26 micro-mol/L, urea 2.5 mmol/L)

· Nasal cannula

· Simple face mask

· Non rebreather

· High flow nasal cannula

· Electrolyte was sent every 8 hours and corrected accordingly

· VBG and ECG was sent every 2 hours

· Piperacillin-tazobactam 4.5 mg IV started for the patient

· Internal medicine consultation

· Psychiatric consultation

Day 1 after ED presentation

· GCS 15/15

· No seizure attack

· Neurological examination intact

· Abdomen is soft and lax

· Chest: Crepitation over the left lung

· Cardiovascular: Normal S1, S2, no added sound

CBC: (WBCs 10.9 10^*3/uL, absolute neutrophils 10.1 10^*3/uL, RBCs 2.13 10^*6/uL, hemoglobin 7.4 g/dl, platelet 94 10^*3/uL)

Renal function test: (Na: 122 mmol/L, k: 4.6 mmol/L, corrected calcium 2.08 mmol/L, phosphorus 0.73 mmol/L, magnesium 0.36 mmol/L, creatinine 32 micromol/L, urea 1.4 mmol/L)

plasma osmolality 255 mOsm/kg

· Free water 200 ml orally every 6 hours

· High flow nasal cannula was weaned

· Piperacillin-tazobactam continued

· Chest X-ray repeated (the result was similar to the previous)

Day 2 after ED presentation

· Patient was doing well, oriented to place Time and person.

· GCS 15/15

· Patient was clinically and Vitally stable

CBC: (WBCs 7.63 10^*3/uL, absolute neutrophils 6.02 10^*3/uL, RBCs 4.07 10^*6/uL, hemoglobin 12.7 g/dl, platelet 192 10^*3/uL)

Renal function test: (Na: 140 mmol/L, k: 4.1 mmol/L, corrected calcium 2.07 mmol/L, phosphorus 0.53 mmol/L, magnesium 1.03 mmol/L, creatinine 62 micro-mol/L, urea 2.1 mmol/L)

plasma osmolality 295 mOsm/kg

Chest X-ray: Interval improvement in aeration in both lungs

· Electrolyte corrected

· Piperacillin-tazobactam continued

Day 3 after ED presentation

· Patient was doing well, oriented to place and person.

· GCS 15/15.

· Patient was clinically and vitally stable.

CBC: (WBCs 5.67 10^*3/uL, absolute neutrophils 3.25 10^*3/uL, RBCs 3.74 10^*6/uL, hemoglobin 11.6 g/dl, platelet 179 10^*3/uL)

Renal function test: (Na: 143 mmol/L, k: 4.3 mmol/L, corrected calcium 2.07 mmol/L, phosphorus 0.77 mmol/L, magnesium 0.73 mmol/L, creatinine 39 micro-mol/L urea 2.8 mmol/L)

plasma osmolality 311 mOsm/kg

· Patient discharged with good neurological outcome

· Discharged on augmentin for 7 days