34 year male with seizures
August 28, 2022
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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 a diagnosis and treatment plan.
Our 34yr old male patient came to the opd with chief complaints of
Involuntary movements(to and fro) of upper limbs since 30minutes.
Hopi:
Patient was apparently asymptomatic 30minutes ago later developed involuntary generalised movements of upper limbs and lower limbs for which he came to hospital and the episode lasted for 30 minutes associated with uprolling of eye balls and frothing.
No h/o tongue bite.
No regained consciousness during in last 30 minutes during seizure episode.
No h/o fever, giddiness, headache, vomiting.
Past history:
Similar complaints in 6yrs back and is not on any medication.
Not a k/c//o DM HTN TB CAD and asthma
Family history:
Not significant
General examination:
Patient is c/c/c
Temp: 98.6F
BP: 100/70mmhg
PR: 86bpm
RR: 14cpm
pallor present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
Systemic examination:
CVS :S1 S2 sounds heard
RS: BAE+,clear
P/A: Soft and non tender
CNS:
R. L
Power. UL. 4/5. 4/5
LL. 4/5. 4/5
Tone- increased in all 4limbs (Hypertonia)
Reflexes:
Biceps Rt ++ Lt ++
Triceps Rt + Lt ++
Supinator Rt + Lt +
Knee Rt ++ Lt ++
Ankle Rt + Lt +
B/l Plantars mute
Sensory: Intact
Cranial nerves:
II III IV V VI VII IX X Functionally intact
Rest could not be examined
Cerebellum: unable to elicit cerebellar function tests
No nystagmus
USG
Chest x-ray
Hemogram 29/08/2022
Hemogram 30/08/2022
RBS:79mg/dl
Serum creatinine:0.7mg/dl
Diagnosis:
Generalised tonic seizures
K/c/o cerebral palsy
TREAMENT:-
1. IV fluids NS,RL @100 ml /hr.
2.INJ.LEVIPIL 1gm IV/stat->500mg IV/BD
3.INJ .monocef 1gm IV/BD
4.INJ.PAN 40 mg IV/OD
5.INJ.ZOFER 4mg IV/soa
6.INJ.LORAZ 2cc IV/sos.
7.INJ.optineuron 1amp in 100ml NS IV/OD
8.TAB.DOLO 650 mg sos
Discharge summary
