Seizures
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
K.shirisha
Rollno;60,
9th semester
Following is the view of my case;
75 year old female occupation by anganwadi ayamma.had brought to casuality on13/03/22
Chief complaints ;
Sudden involuntary movements of upper and lower limbs at 11;30am .on13/3/22.
C/o tongue biting
C/o froth
C/o mouth deviation
History of present illness;
The patient was alright 1 day back then she developed sudden involuntary movements of both upper and lower limbs.
With 2 episodes
1st episode around 11;30pm with tongue biting,and froth
2nd episode around 2pm. With sudden involuntary movements of both upper and lower limbs.with tongue biting and froth coming from mouth.
C/o headache since 5- 6 days,post ictal confusion for 15 minutes.
No c/o involuntary micturition and defecation.
Past history;
No history of similar complaints in the past.
Not a k/c/ o hypertension,diabetes,asthma, thyroid disorders ,heart disorders.
Family history ; insignificant
Personal history;
Appetite ; decreased since 3 months
Diet ; mixed
Bowel and bladder; regular
Sleep ; inadequate
Addictions; occasional toddy drinker.
General examination;
The patient was not conscious, at the time of presentations.
Now she was conscious, coherent and cooperative
Moderately built and moderately nourished.
Pallor: absent
Icterus absent
Cyanosis absent
Clubbing absent
Edema absent
Lymphadenopathy absent
Vitals;
Temperature 98.4°F
Blood pressure 130/70mmhg
Heart rate 80bpm
Respiratory rate 18cpm
Spo2 98%@ra
Grbs; 135
Systemic examination
Central nervous system; E4V5M6
Level of consciousness: normal
speech was normal
No meningeal signs
Cranial nerves ;
1) olfactory nerve ; percieves smell on both sides
2) optic nerve : normal visual acuity
3) occlomotor nerve ; normal
4) trochlear nerve ; normal
6) abducens nerve ; normal
(3,4,6 cranial nerves) ; ptosis,squint, nystagmus - absent.
* Ocular movements- present in upward,downward,temporal,nasal gaze
* Pupil- size- normal,shape- central
* Visual reflexes- direct, indirect- reacting to light
5) Trigeminal nerve ; cutaneous sensibility over skin and mucous membranes - present
✓ corneal reflex- present on both sides
✓ deviation of jaw on opening mouth- absent
7) facial nerve; normal
8) vestibuli cochlear nerve; normal
9) glossopharyngeal nerve; Taste sensation on posterior 1/3rd of tongue - present on both sides
✓palatal reflex- present on both sides
10)vagus nerve ; no history of regurgitation of fluids through nose
Palatal reflex- present
11) spinal accessory nerve ; normal
12) hypoglossal nerve ; normal
Motor system
Gait; normal
Power U/L L/L
Right 4/5 4/5
Left 4/5 4/5
Tone U/L L/L
Right normal normal
Left Normal Normal
Reflexes Biceps triceps supinator knee ankle
Right 2+ 2+ 2+ 2+. 2+
Left 2+ 2+. 2+. 2+. 2+
Pupil : reacting to light
Bilateral plantar reflexes mute( babinskis sign - positive)
Conjunctival reflex +
Corneal reflex+
Sensory system ; normal
Cardiovascular system;
S1,S2 heart sounds heared,no thrills and murmurs
Respiratory system;
BAE-PRESENT
Normal vesicular breath sounds,no wheeze or no adventitious sounds
Per abdomen ;
Shape of abdomen ; scaphoid, soft, no
tenderness
No palpable masses
Hernial orifices are normal
No free fluid,no bruits and engorged veins
No organomegaly
Bowel sounds are heared
Investigations;
Investigations;
Complete blood picture
HB; 10.5
TLC;12,400
Neutrophils; 89
Lymphocytes; 96
Eosinophils: 02
Monocytes: 03
Platelet count; 2.25
RBS; 141
Renal function tests;
Urea:24
Creatinine; 0.8
Uric acid: 3.6
Calcium; 9.5
Phosphate; 2.9
Sodium; 140
Potassium; 3.6
Chloride; 99
Liver function tests;
TB;0.52
DB;0.16
AST;32
ALT;14
ALP;150
Tp; 6.9
Albumin;4.3
A/G : 1.68
ABG ;
Ph;7.407
Pco2; 29.9mmhg
Po2; 87.9mmhg
S02:95.6%
Sodium;136mmol/L
Potassium;3mmol/l
Calcium;0.78
Chloride; 102
Bicarbonate;20.5(standard)
Bicarbonate p)c; 18.5
2d echo
Management;
✓inj levipil 1gm iv bd
✓ inj pan 40mg iv od
✓ inj zofer 4 mg iv od
✓ inj optineuron 1ampoule in100 ml ns iv od
✓ Bp,pr charting 4th hrly
✓temperature charting 4th hrly
✓ Grbs charting 12 th hrly
Comments
Post a Comment