A 17 years old female with recurrent attacks of seizures.
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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.
Involuntary movements of both upper limbs and lower limb since 12 pm.
HOPI:
She was apparently asymptomatic till the age of 6 years then she developed fever with chills for 1 day .
The next day she developed involuntary movements of upper and lower limbs.
The last episode was today at 2 pm(2 Dec2022) which lasted for 30 minutes associated with uprolling of eye balls followed by post ictal confusion,no micturition,no defection and no frothing from mouth.
She had history of headache and syncope.
She was taken to hospital at the age of 6 years then was admitted to the hospital and received medication and then she had the recurrent attacks even after medication frequently.
After the episode of seizures she had the recurrent falls which caused trauma to the head.
Few years ago when she was admitted to the hospital CT scan was done which revealed atrophy of right cerebral hemisphere. She has been on valproate .
After they visited other hospital as she was micturating following each seizure episode they started on tablet Lamotrigine.
After admission to the hospital from yesterday she had 5-6 brief episodes.
Past history:
No history of hypertension
No history of Diabetes
No history of CAD
No history of tuberculosis
No history of Asthma.
Personal history :
Her appetite was decreased since 1 week.
Has inadequate sleep since 1 month .
Bowel and bladder: Regular
Diet - mixed
Addictions- none
She performs her daily activity.
But since 1 month she was unable to perform.
She studied till LKG then stopped the school due to recurrent episodes.
Obstetric history:
Term baby
Birth weight 2.25 kg
Cried immediately after birth.
No hospital admission immediately after birth.
Achieved milestones according to her age.
Family history :
No relevant family history.
Treatment history:
Patient was on anti epileptic drugs from the age of 6 years.
General examination :
Patient is not conscious, coherent and cooperative not well oriented to time ,place and person.
No pallor, icterus,cyanosis, clubbing, lymphadenopathy, Edema.
Vitals:
Temperature: 98.6F
Pulse: 87 bpm
Respiratory rate :20cpm
Blood pressure:120/80 mm Hg
CNS Examination:
As she was not conscious , oriented to time, place and person
Her speech , behaviour and memory are not intact
Sensory system:
Fine touch : not intact
Pain : no sensation
Temperature: no response to heat or cold
Vibration: not intact
Two point discrimination test: absent
Motor system examination:
Right. Left
Tone
Upper limb normal. Normal
Lower limb normal. Normal
Reflexes:
Biceps 2+. 2+
Triceps. 2+ 2+
Supinator 2+. 2+
Knee. 2+. 2+
Ankle. 2+. 2+
Power cannot be elicted as the patient is unconscious
Cerebellar function test:
Cannot be elicted
Gait cannot be elicted
Systemic examination
Cvs
S1,s2 heard ,no murmur,apex beat at mid clavicular line at 5 th intercoastal space.
Respiratory system
I: Chest bilaterally symmetrical, all quadrants
moves equally with respiration
P: Trachea central, chest expansion normal
P: Resonant
A: B/l equal air entry
B/I VBS
no added sound
Per. Abdominal examination :-
I normal
P soft non tender
No organomegaly
Investigations
Treatment -
Injection- levipil 500mg IV bd
Injection - lorazepam 4mg IV
Injection - optineurin 1ampoule in 100ml normal saline over 30 minutes
Injection - sodium valproate 500mg IV bd .
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