20 YEARS OLD MALE WITH SEIZURES
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I've 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 a diagnosis and treatment plan.
K.Vyshnavi
Roll No - 70
PATIENT CAME TO THE OPD,WITH THE CHIEF COMPLAINTS OF :
Involuntary movements of Left Upper Limb and Lower limb since 28.12.2022 night to morning he had 6 episodes
Patient was apparently alright till 28.12.2022 night and then he had involuntary movements of left upper limb and lower limb. Each episode lasts for 2 minutes associated with loss of consciousness, tongue bite, post ictal confusion. According to his parents he didn't take medication from 2 days prior to this episode of seizures
He had similar complaints in past
1st episode was at birth
2nd episode was at 6th month of age(febrile seizures)
And then next episode was at 7years of age. Then at 14 years of age. From then he had many episodes like these regularly and was on medication.
No H/O Fever, Cold ,Cough , loss of appetite , Burning Micturition
PAST HISTORY:
K/C/O Epilepsy since 12 years(Not on regular medication)(He was using oxcarbazepine450mg, Bruvaracetam50mg, Phenytoin, Phenobarbitone, Resperidone, Trihexyphenidyl)
K/C/O Mental retardation (Resperidone)
Not a K/C/O HTN, DM II ,Asthma ,TB , CAD ,CVD
PERSONAL HISTORY :
Appetite -Normal
Diet - Mixed
Sleep - adequate
Bowel and bladder movements -Regular
Addictions: No addictions
Allergies : No allergies
Mentally retarded from birth ( he can't read or understand words or numbers,write,eat properly)
GENERAL EXAMINATION:
Patient is conscious ,coherent , cooperative, thinly Built and Moderately Nourished .
He was examined under well lit room with consent taken
Temp: 98.2F
BP : 110/60 mmHg
PR : 70bpm
RR : 22cpm
Pallor : absent
Icterus : absent
Cyanosis: absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent
SYSTEMIC EXAMINATION:
CNS :
RT LT
Tone : UL : Hypertonic N
LL : Hypertonic N
Power : UL -5/5 5/5
LL- 5/5 5/5
R. L
Reflexes : biceps: 3+ 2+
Triceps : 3+ 2+
Knee: 3+ 3+
Ankle :2+ 2+
Supinator : 1+ 1+
Babinsky :
Plantar. Flexion on both sides
Cereblellar signs : R L
DISDIADOKINESIA Able Able
Finger nose test + +
Kneel heel test + +
Meningeal signs like : neck stiffness , kerning sign,brudzinsky sign are negative
CVS : S1 S2 + ,no murmurs
RS : BAE Present
P/A : Soft and Non tender
INVESTIGATIONS
29/12/22
HEMOGRAM
Hemoglobin: 13.8
TLC: 10,200
Platelet: 3.14
MCV: 85.2
MCH: 28.8
PCV: 40.0
RBC COUNT: 4.80
ELECTROLYTES
Na: 138
Cl: 102
K: 3.8
Ca ionised: 1.03
RBS- 86
RENAL FUNCTION TESTS
Urea: 35
Creatinine: 0.6
LIVER FUNCTION TESTS
Total Bilirubin: 0.62
Direct Bilirubin: 0.16
SGOT(AST): 49
SGPT(ALT): 58
ALP: 291
Total Protein: 6.3
Albumin: 3.7
A/G: 1.48
Serology - Negative
Generalsied Tonic Clonic Seizures
K/C/O Epilepsy since 12 years ( Drug defaulter) with MA
Treatment:
Inj.Levepil 1000mg in 100ml NS iv/stat
Inj.Sodium valproate 2mg iv/stat
T.Sodium Valproate 500mg PO/BD
T.Oxcarbazepine 450 mg PO /BD
T.Resperidone 1mg PO OD H/S
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