34 year old female with seizure attack

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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


The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt. 



Patient came to casualty with C/O

C/O involuntary movements of both upper limb and lower limb lasted 2 mins at 2AM 2 similar episodes yesterday Post ictal confusion + and Tongue bite +

HOPI:

Pt was apparently asymptomatic 1 days back then she developed 2 episodes of seizures at 2AM presented as involuntary movements of both upper limb and lower limb with post ictal confusion, clenching of fist and Tongue bit

No H/O fall, involuntary micturition and defecation, fever, vomitings

K/C/O Epilepsy since 14 years(not on regular medications)(alternate day T.levipil 500mg)

Similar 1 episode @5yrs back

N/K/C DM,HTN,TB,asthma,Thyroid,CVA,CAD

Pt has no pallor, icterus, cyanosis, clubbing, lymphadenopathy, generalised oedema

Vitals (On admission):

Pt is C/C/C

Temp:98.1F

PR:94bpm

BP:120/80mmhg

SpO2:99

General examination:

CVS:S1S2+

RS:BAE+

PA:soft,NT,bowel sounds+

CNS EXAMINATION: 

1. HIGHER MENTAL FUNCTIONS:

    Patient is Conscious coherent cooperative 

    Speech-high pitch

2.CRANIAL NERVES: INTACT

3.MOTOR

           Power                 Right                   Left

               Upper limb        5/5                  4/5

               lower limb         4/5                  4/5

       Tone                             Right                  Left

                    Upper limb        N                        N

                    Lower limb        N                        N

Reflexes:                    Right                 Left. 

Biceps.                          ++                   +++

Triceps.                         ++                    ++

Supinator.                     +++                   +++

Knee.                             ++                    ++

Ankle.                            ++.                    ++

4.SENSORY

    spinothalamic

           crude touch                N                          N

           pain                             N                          N

           Temp                           N                         N

    post column

             fine touch                  N                        N

             vibration                    N                        N

             position sense         8/10             8/10

             Romberg's: negative 

    cortical

              Stereognosis: N

5.CEREBELLAR:Normal

Diagnosis: ?GTCS



Treatment:

Day-1:
1.INJ.LEVIPIL 1GM IV IN 100ML NS STAT
2.INJ.LEVIPIL 500MG IV IN 100ML NS BD
3.T.FRISIUM 10mg PO OD 
4.T.OPTINUERON 1 ampule in 100ml NS/IV/OD

Day-2
1.INJ.LEVIPIL 500MG IV IN 100ML NS BD
2.T.FRISIUM 10mg PO HS

Day-3
1.INJ.LEVIPIL 500MG IV IN 100ML NS BD
2.T.FRISIUM 10mg PO HS

Day-4
1.INJ.LEVIPIL 500MG IV IN 100ML NS BD
2.T.FRISIUM 10mg PO HS

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