18 yr old female with seizures

-

 This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from an available global online community of experts to solve those patients clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome.


 


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 diagnosis and treatment plan.



Following is the view of my case :

Date of admission : 13/11/22

Chief complaints :

C/O INVOLUNTARY MOVEMENTS OF ALL THE FOUR LIMBS AT 10:30 PM ON 12/11/22


History of present illness : 

18 YEAR OLD WAS APPARENTLY ALRIGHT TILL YESTERDAY NIGHT ,WHILE SHE WAS WATCHING TV,SHE SUDDENLY DEVELOPED INVOLUNTARY MOVEMENTS OF THE 2 LIMBS() associated with frothing,uprolling of eye balls which lasted for about 1-2 mins followed by post ictal confusion which is for about 5 minutes,No c/o involuntary micturition,tongue bite was present

Past history:

K/c/o Hypothyroidism 2 yrs back(stopped using medication since 1 year)

H/o PCOD 1 yr back

N/k/c/o htn,tb,dm,asthama, epilepsy

Family History:

Not Significant

Personal History:

Diet - mixed

Appetite - normal

sleep - adequate

Bowel and Bladder movements -regular

Addictions - no

No known allergies

Drug history : 

No significant drug history

General examination :

Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person 

at the time of examination

SHe is examined in a well lit room, with consent taken.

SHe is moderately built and well nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent

Vitals : on the day of admission 

Temperature - afebrile

Pulse rate - 84 bpm

Respiratory rate - 16 cpm

Blood pressure - 120/70 mmHg

SpO2 - 98% on Room air

GRBS - 117mg/dl

Systemic examination :

CVS : S1 and S2 heart sounds hear

NO murmurs and thrill

RESPIRATORY SYSTEM : Bilateral air entry present             

position of trachea - central 

Vesicular breathsounds heard

CNS : 


ABDOMEN 

Soft

Non tender

No palpable mass

 Bowel sounds heard

 NO organomegaly 

Investigations:




Diagnosis:

seizures under evaluation

Treatment:

1.Inj.LEVIPIL 500MG IV BD

2.INJ.OPTINEURON 1AMP IN 500ML NS IV OD

3.MONITOR VITALS AND INFORM SOS


Comments

Post a Comment

Popular posts from this blog

45 year old male patient with swelling over legs and abdomen and lower back pain and renal failure

-
Image
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. 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. Following is the view of my case CASE : A 45 year old male patient with swelling over legs and abdomen since 3 months and back pain since 1 month  HISTORY OF PRESENTIMG ILLNESS  •Pt was apparantly asymptomatic 13 years back then he had episode of loss of consciousness with  bi
Read more

50 year old male patient with weakness in right and left lower limbs and slurred speech

-
Image
  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient' problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 50 year old male with  weakness of both lower limbs   and slurring of speech since 5 days History of presenting illness : Patient had a history of fall 1 year ago and he did not take any treatment for it and was alright for 8 months then 4 months back he had pain in right hip which was insidious in onset and gradually progressive in nature   since 1month there was change in the gait of patient which was noticed by his relatives and there is hematuria for 5 days which he has neglected For which he consulted local doctor and diagnosed avascular necrosis of of femur for which he has given medication Aft
Read more

Internship assessment

-
 Unit duty: Most of the time in the unit we (internees) are assigned the responsibility of patients, So in that process we took the blood samples(for cultures too),collected their reports,updated in our respective whatsapp groups,got their ECGs,2D ECHOs,USGs,X-rays,done,filmed their 2d echo videos,made fever chartings and updated the case sheets, monitored vitals I had put Foley's catheter and Ryles tube,for some patients In OP I learned how to take patients complaints in brief,checked their vitals,examined CNS,P/A for few patients and learned to prescribe few medications and to few advised and motivated them to get IP for their own benefit Here are some of the cases I made blogs about their condition Case 1 https://saichennuru.blogspot.com/2022/10/29-year-old-with-fever-and-loose-stools.html Case 2 https://saichennuru.blogspot.com/2022/10/old-female-with-fever-and-sob.html Case 3 https://saichennuru.blogspot.com/2022/11/is-online-e-logbook-to-discuss-our.html Case 4 https://saiche
Read more