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;

✓Inspection;

Position of trachea ;midline

No visible pulsations,no raised jvp

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Upper part of chest depression is seen

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

✓Palpation; no tenderness,no local rise of temperature,all inspectory  findings are confirmed nopalpable thrills,parasternal heaves are palpable

✓Percussion ; Heart borders;

     Left border; 1.5cm internal to mid clavicular line

      Right border of heart; right of sternum at the level of 4th rib

      Upper border of heart; cannot be defined as dullness of heart tissue continues with dullness of big vessels

      Lower border of heart : cannot be defined ,as it lies in relation with the diaphragm and left lobe of liver below it

✓ Auscultation; 

S1,S2 heart sounds heared,no thrills and murmurs

Respiratory system;

Inspection of upper respiratory tract;

Oral cavity ; normal

Nose; no DNS,polyp

Pharynx ; normal

✓Lower respiratory tract;

Position of trachea; midline

Position of Apex beat; left5ics 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movement of chest ; normal

 

✓Palpation ;

Position of trachea,apical pulse is confirmed

No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub

* Vocal fremitus ; vibrations of chest are equal

✓Percussion;

Resonant note heared,no obliteration on traubes space

✓Auscultation;

 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

Mri brain

Ecg

2d echo

Chest x ray

Provisional diagnosis;

Seizures under evaluation.

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