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