Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
A18 year old female came to the opd with the chief complaints of seizures and loss of consciousness at 10:30pm on 12/11/2022.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic till yesterday while she was watching tv, she suddenly developed involuntary movement of 4 limbs associated with frothing, uprolling of eye balls which lasted for about 1-2 mins followed by post ictal confusion which is for about 5 minutes,No c/o involuntary micturition,tongue bite was present.
No aggrevating or relieving factors.
No associated symptoms present.
PAST HISTORY:
K/c/o Hypothyroidism 2 yrs back(stopped using medication since 1 year)
H/o PCOD 1 yr back
N/k/c/o DM , hypertension, asthma, epilepsy,TB, CAD,CVA.
FAMILY HISTORY:
Not significant.
PERSONAL HISTORY:
Diet - mixed
Appetite - normal
sleep - adequate
Bowel and Bladder movements -regular
Addictions - no
No known allergies
DRUG HISTORY:
No significant drug history.
GENERAL EXAMINATION:
Patient is conscious ,coherent, cooperative and was well oriented to time, place and person .
She is moderately built and well nourished.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
lymphadenopathy - absent
Pedal edema - absent.
VITALS:
Pulse rate - 84 bpm
Respiratory rate - 16 cpm
Blood pressure - 120/70 mmHg
SpO2 - 98% on Room air
GRBS - 117mg/dl
Temperature: Afebrile.
SYSTEMIC EXAMINATION:
CVS : S1 and S2 heart sounds heared
NO murmurs and thrill
RESPIRATORY SYSTEM : Bilateral air entry present
position of trachea - central
Vesicular breath sounds heard.
CNS : No focal deficits are found.
ABDOMEN :
Soft
Non tender
No palpable mass
Bowel sounds heard
NO organomegaly .
Provisional diagnosis:
seizures under evaluation.
Investigations:
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