18F with single episode seizures
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I have been assigned this case to develop my competency in reading and comprehending clinical data, including the patient's history, clinical findings, and investigations, in order to come up with a diagnosis and treatment plan.
Case taken by Sangha Mithra and M.sravanthi
Case Summary:
Patient Information
- 18-year-old female resident of Miriyalaguda, Who is a student brought to opd with
Chief Complaints:
Loose stools since 10 days.
Vomitings from 10 days.
Abdominal pain from 4 days
Seizure activity at 2 am on 22 June.
History of Presenting Illness:
Patient was apparently asymptomatic 4 years ago,then she developed fever,
After 1 day she developed vomitings ,abdominal pain and headache.she was admitted in hospital for 15 days where she was diagnosed with anaemia. _
She also developed dyspepsia .
She had 3 episodes of fever in the last 4 years which usually lasts about 3 to 4 days so she would visit hospital in Hyderabad and take medication. Her fever was subsided by medication.
1 year ago she developed blood in stools and abdominal pain then she visited doctor and took medication for 1 week and the symptoms were relieved
4 months ago she got typhoid fever ,from then her appetite was decreasd and doctor gave some medication ?? With that her appetite increased.
she changed her diet and started eating healthy
1 week back she developed vomitings 6-8 episodes perday sudden onset ,within 2 hours of consumption of food ,non blood stained,non blood tinged , food as contents associated with nausea.
Abdominal pain since 4 days which is initially diffuse now it is only in the umbilicus region.
She was admitted in hospital on 21 June -
They gave some medication and she slept at 12 am. At 2 am she developed fits which lasted for 2 min associated with uprolling of eyeball , drooling of saliva, loss of consciousness, involuntary micturition.following the episode patient was in confusion and she doesn't remember anything about the night.patient was given midazolam500 mg and referred to our hospital for further evaluation.
On 23 Rd June she has generalised weakness and bodypains.
No h/o of outside food consumption.
No h/o headache,fever,hemetemesis ,melena.
Past History:
- No known case of chronic obstructive pulmonary disease (COPD), tuberculosis (TB), asthma, hypertension (HTN), coronary artery disease (CAD), cerebrovascular accident (CVA), epilepsy, or thyroid disease.
Family History:
- Not significant.
Personal History:
- Mixed diet, normal appetite, No addictions.
Menstrual history:
Attained menarche at 11 years
Lmp: 22 may
6 days flow without clots associated with severe backache
Uses 8 pads per day.
Pyschosocial history:
Patient was apparently asymptomatic 1 year back then one fine day when she's going to her college she stopped on the way at her father tea shop near college after speaking to pateint, her father went upstairs and while coming back he noticed that his daughter was unable to recognise him and only able to remember her mother , patient mother said she's calling her father as uncle and she wasn't able to recognise him. Following these events she was taken to a faith healer who performed a ritual which lead to her getting back to normal and recognising people but patient mother telling that the pateint did not remember anything that happened during that particular period of time .
Since then patient started seeing shadows of snakes in her house ( crawling) on the floor. Also she says she felt that someone is next to her whenever she is walking inside her home alone so as such events are repeating more she was taken back to faith healer again after which she got better.
Patient mother says that , patient was fine since 2 months without any new episodes but experiencing bouts of vomitings abdominal pain due to which she was brought here at 22nd morning 6am and she was under going treatment and at around 2pm she started saying that someone is calling her unknown voice from left side 1 in number.she says she want to go and see who is calling her.
General Examination:
- The patient is conscious, coherent, cooperative, thin-built, and nourished.
- Examination performed in a well-lighted room
- Pallor ,icterus, cyanosis, clubbing, generalized lymphadenopathy, and bilateral pedal edema are absent.
Vital Signs:
- Blood pressure: 90/60 mmHg
- Pulse rate: 78 bpm
- Respiratory rate: 18 cpm
- Oxygen saturation (SpO2): 99% on room air
Systemic examination:
CNS :
Mental state examination:
Appearance : hygiene maintained groomed
Mood : fine ( she wants to go home or she wants her phone back )
Thought process : normal
Perception : auditory and visual Hallucinations ( seeing snakes and someone calling her)
Orientated and conscious
Memory: long term :good
Short term : on 22nd June after 12am she wished her sister and slept after that She doesn’t remember anything till today morning she just remembered one or two events from yesterday
Immediate: good
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : Visual acuity is normal
3rd,4th,6th : Pupillary reflexes present
EOM full range of motion present
5th : Sensory intact
Motor intact
7th : normal.
8th : No abnormality noted.
9th,10th,11th,12th : normal.
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch Present
Pain Present
Temperature Present
DORSAL COLUMN SENSATION:
Fine touch Present
Vibration Present
Proprioception Present
CORTICAL SENSATION:
Two point discrimination Present
Tactile localisation Present
CEREBELLAR EXAMINATION:
Finger nose test able to perform
Heel knee test able to perform
Dysdiadochokinesia able to perform
Speech Normal
Rhombergs test Absent
SIGNS OF MENINGEAL IRRITATION:
Kernig's sign, brudzinski sign, neck rigidity absent
MOTOR EXAMINATION:
Right Left
UL LL UL LL
BULK: Normal Normal Normal Normal
TONE : Normal Normal Normal Normal
POWER : 5/5. 5/5. 5/5. 5/5
SUPERFICIAL REFLEXES:
CORNEAL present
CONJUNCTIVAL present
DEEP TENDON REFLEXES:
https://youtube.com/shorts/kqbJH1j1TY0?feature=share3
https://youtube.com/shorts/TJu5Pa5adv8?feature=share3
Right Left
BICEPS. + 2 + 2
TRICEPS + 2 + 2
KNEE + 3 +2
ANKLE + 2 +2
Per abdomen:
Inspection:
Shape of abdomen: flat
Umbilicus: Inverted and central
No visible pulsation, scars, swelling, sinuses, dilated veins .
Palpation:
No local rise of temparature and tenderness
Percussion:
No fluid thrill, shifting dullness absent
Auscultation:
Bowel sound heard
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:No local rise of temparature and no tendersness
Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line
Position of trachea was central
Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
Provisional diagnosis:
seizures under evaluation ?Acute gastroenteritis ?
Investigations?
22/6/23:
Hb: 10.5 gm/dl
TLC: 6600 cells/ cumm
RBC: 4.54 million/cumm
PLT: 2.44 lakh/cumm
PCV: 33.2 vol%
Neutrophils:88%
Lymphocytes:10%
MCV:72.8fl
MCH:23pg
Blood urea: 19 mg/dl
Serum creatinine: 0.8 mg/dl
Serum electrolytes:
Na+: 140 mEq/l
K+: 4.3 mEq/l
Chloride : 102 mEq/l
Total bilurubin:0.94mg/dl
Direct bilurubin :0.20 mg/dl
AST:16 IU/L
ALT:20 IU/L
Alk phosphatase:174IU/L
Total Protien:6.8gm/dl
Albumin:3.9gm/dl
CUE:
Albumin:nil
Sugars:nil
Pus cells:2-3/HPF
Epithelial cells:2-3/HPF
TREATMENT:
Inj.zofer 4mg IV/tid
Inj.pan 40mg IV /OD
Inj.buscopan IV/BD
IV fluids -NS,RL,DNS @100ml/hr
Inj.optineuron 10mg
Inj.metrogyl 500mg IV/TID
Inj.levitiracetam 500mg iv/bd
23/06/23
Date of Admission :- 22.06.2023
ICU bed -1
S:
C/o pain in hypogastric region
No fever spikes
Stools passed in morning
O:
Patient is c/c/c
Temp: 98.6 F
PR- 89 bpm
RR-18 cpm
BP-100/70 mm of Hg
Spo2 -98%
CNS:
GCS- E4 V5 M6
Pupils NSRL
Tone- Normal in all four limbs
Power -
Rt Lt
UL 5/5 5/5
LL 5/5 5/5
Reflexes
Rt Lt
B - 1+. 1+
T - 1+. 1+
S. -. -
K - 2+. 2+
A - 2+ 2+
Plantar
Right-Flexor Left-Flexor
RS-B/L air entry present, NVBS
CVS- S1S2present, no murmurs heard
PA- soft, tenderness present in hypogastric region,bowel sounds +
A:
Seizures under evaluation -?drug induced
?ofloxacin
Acute GE
P:
1.Iv fluids 2NS,1RL1DNS@1
00ML/HR
2.Inj.lorazepam 1mg IV/SOS(if sleep disturbances are present)
3.Monitor vitals
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