A 55year old female with h/o seizures

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

This blog is done by 103.Pavan.Ch & 104.Jeshmitha.P

A 55yr old female resident of chityal with history of seizures 

Chief complaints:-

The patient was brought to casuality with cheif complaints of Active involuntary movements ,since 30 minutes, history of frothing from mouth deviation of eyeball upwards ,toungue bite with urinary incontinance no h/o of fever, head injury, vomitings, loose stools.

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 20 yrs back later she developed sudden onset of movements in upper and lower limbs for 5 minutes , confusion 

The frequency & duration  of episodes were gradually increasing with in these 20 years 

Initially it was 1 episode in 5 yrs ---->later 2-3 episodes within 5yrs ----->one episode in 2years ---> single episode in 1yr ---->2-3 episode in a year 

Last episode - 

Current presentation - 

on 1 dec she 5-6 episodes of seizures lasting for 10 mins,associated with confusion after the episode triggered by unilateral headache (30 mins prior to onset of symptoms), stiffening,  sudden onset of involuntary movements, confusion uprolling of eyes, frothing, involuntary micturition. deviation of mouth towards left and postictal clouding.

H/o one episode of seizure activity after bringing to casualty 

no h/o of involuntary defecation

no h/o fever, cough, vomitings, loose stools, pain in abdomen.

PAST HISTORY:-

K/C/O  epilepsy since 20  years on medication not a known case of DM/HTN/TB/Asthma/CVD/CAD

TREATMENT HISTORY:-

On treatment for epilepsy since 20 yrs 

PERSONAL HISTORY:-

diet: mixed

 Appetite: normal

sleep: adequate

bowel and bladder:normal

no addictions

FAMILY HISTORY:-

Not relevant  

GENERAL EXAMINATION:-

Patient is drowsy and irritable 

moderately built and nourished 

Pallor - Absent

Icterus - Absent

Cyanosis -  Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal edema-absent

VITALS:-

Tempurature - 102.2 F

Pulse- 128 bpm

Blood pressure - 140/90 mmhg

Respiratory rate - 28 cpm

spo2- 94

grbs- 222mg/dl

SYSTEMIC EXAMINATION:-

CVS- 

Inspection:-

JVP not seen

Auscultation

S1 S2 heard , no murmurs 

RESPIRATORY SYSTEM

chest is bilaterally symmetrical 

bilateral airway entry present

trachea - Midline 

no scars

Percussion:-Resonant in nine quadrants

Auscultation- Normal vesicular breath sounds heard

ABDOMINAL EXAMINATION

shape- scaphoid

no tenderness

liver not palpable

spleen not palpable

CNS EXAMINATION 

level of consiousness:- stuporous

speech- no response

Attitude and position - patient was lying on the bed in supine position 

Bulk - 

            

                        Rt.                  Lf 

arm.               25 cm.           25cm

Forearm.        20cm.           20cm

Thigh.             35cm.            30cm

Leg.                 28cm.             28cm

signs of meningeal irritation-

neck stiffnes- no

kernigs sign-no

cranial nerve examination- cannot be elicited 

motor system

sensory system- cannot be elicited

glassgow coma scale- E1 V1 M6

Pupils - reactive to light 

Tone -    Rt.                 Lf

UL.        Normal.        Normal

LL.        Normal.         Normal

 Power                Rt.                 Lf

UL.                 Absent.            Absent

LL.                Absent.             Absent 

Reflexes -

superficial reflexes 

    cornea-  present

    conjunctiva - present

   

Deep tendon reflexes-         

                Rt.          Lt 

Biceps:            2+         2+

Triceps           2+.        2+

Supinator.       1+         1+

Knee.               1+          1+

 Ankle            absent.    Absent 

biceps reflex

knee reflex

supinator reflex

Cerebellar signs cannot be elicited.       

gait- cannot be elicited

PROVISINAL DIAGNOSIS- GTCS secondary to acute CVA

INVESTIGATIONS:- ON day1

ULTRASOUND 

TREATMENT : 

She was given

 Inj.loraz 2cc IV

Inj.Neomol 1gm 

Inj.nevipil 1gm