- 18 year old

- Male
- Syncopal attack for 1 time
- Generalized tonic conic seizure for 4 times
- CVS – CO decrease – Cerebral blood flow decrease – syncope – fits
- Respiratory -

CNS
- Headache
- Weakness
- Loss of conscious
- Slurred Speech
- Swallowing Difficulties

Liver – Hepatic ancephalopathy

Investigation
- CT
- RBS
- Electrolyte – Na **, Ca, Mg
- SPO2
- Semi-Prone position
- Diazepam – depend on the patient (Contra-liver, Alocohol) : Lorazepam (shorting acting)
-

Pre-treatment
- ABC
- RBS – fits, unconscious, metabolic ***
 History
- Syncopal attack
- Fits – GTCS (10-15 min) (>30min status epilepticus – ICU)
- Muscle contraction – muscle breakdown – Rhabdomyolysis – Myoglobinuria
- Tonic fits – respiratory muscle contract (longterm) – brain hypoxia (esp: child)
- Epilepsy – recurrent seizure (tongue biting, urinary incontinence, post ictal confusion)

Fits CNS cause:

- Infective – meningitis, encephalitis **, cerebral malaria
- Neoplastic
- Metabolic
- Inflammatory: SLE
- Toxicology

Epilepsy – EEG

Inv
- CT scan (Head)
- Lumbar Puncture / CSF - infective
- EEG - epilepsy

On examination
- HR – 25bpm, regular, thread pulse
- BP – 80/60 mmHg
- Auscultation – S1+S2+0
- SpO2- 90
- Auscultation – VBS + 0
- Dysponeic
- Cold and clammy extremities
 SHOCK **
- Cardiogenic Shock
- Septic Shock
- Hypovolemic Shock

CNS
- GCS
- Pupil – 3mm, equal on both sides , LR (+)
- Neck – soft (stiffiness + in menigitis)
- Sign of menigism - Absent
- NL motor system examination
- Abdominal examination – NAD

RBS - 6.2 mmol (hypo – 3.9mmol/L)

ECG

- P wave +
- QRS –
- A-V Dissociation – 3rd Heart Block (complete heart block)

Provisional diagnosis
- Cardiogenic shock with complete heart block
Causes of Complete Heart Block
1. Myocarditis
2. Charger disease
3. Drugs : Blocker
4. Fibrosis / Sarcoidosis
5. MI (inferior) (elderly)

- Brady arrythmia – Electrolyte , Thyroid function test

HyperK+ + renal impairment

AKI – Hyper K – Arrhythmia – Heart block – Shock – Fits
Glomerular nephritis – biopsy
- Ig A nephropathy
- APSGN

Acute Glomerulonephritis

Past medical
- Attacked by a swarm of bees one week before - APSGN
- Bee sting – Final diagnosis

Immediate Treatment
 Prognosis

Reversible AKI