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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.
20 year old male with involuntary upper and lower limb(seizures)
CHIEF COMPLAINTS:
4 to 5 episodes of involuntary movements of upper and lower limbs (seizures)from 4 am in the morning (19/07/23) 2 to 3 minutes with up rolling of eyes and froathing mouth .post ictal confusion present for 10 minutes
HISTORY OF PRESENT ILLNESS:
Patient was apparently normal till 7 years of age, he then had an episode of involuntary movements of upper and lower limbs with up rolling of eye lids and froth from mouth. Each episode lasts for 1-2 minutes.
He was then taken to a hospital where he was diagnosed as a case of epilepsy and put on treatment. Post ictal confusion +ve.
Patient was having seizure episode in every 1-2 months and relieved by themselves.
According to parents, the intensity of each attack is increasing from past one year.
Last seizure episode was 6-7 months back.
No h/o vomitings, involuntary passage of urine or stools.
Aggravating factors : fever during rainy season and shivers during contact with cold water.
PAST HISTORY
Patient has h/o delayed milestones.
Patient is k/c/o epilepsy since the age of 7 years (13 years) and medication given was Tab. Sodium valproate 500mg PO/OD, Tab. Oxcarbazepine 450mg BD, Tab. Phenytoin 100mg OD.
Not a k/c/o DM, TB, HTN, asthma, CAD.
DETAILS OF SEIZURES ACTIVITY:
9 months pregnancy - no movements present didn't have labour pain
LSCS done didn't cry ? seizures @8th day in NICU (doctor explianed that baby will will have delayed milestones)
AGE OF 6 MONTHS :
Fever with seizure advised to use antiepileptic for 3 yrs but used only for 6months.
Age 7 yrs:
H/O Fall from bed associated with absent seizure which continued for next 6 months till 9yrs of age.
Age 9yrs:
2-3 seizures every 1 month
Age 10yrs:
Absent seizures later followed by generalised seizures
Age 13 to 19 yrs
Seizure activity for every 1 month
Bending knees while walking
Age 19.5
Admission in kims for seizure activity
Age 20yrs
A gap of 6months present from previous activity
MILESTONE EVENTS DELAYED :
GROSS MOTOR
3 months :lifts head by 5 months
6 months: tripod postion by 8-9 Monty
12 months:14-15 months standing and walking
walking without support @3yrs
3 years:3and half years he started running
5years:5 and 1/2 he started walking up the stairs
FINE MOTOR
3 months: gripping and grasping @ 6 months
2-3 yrs stacking blocks delayed by 2-3 months
SOCIAL AND ADAPTIVE MILESTONES
6 months: couldn't get scared by strangers
9 months: @1 yr couldn't say bye bye
1year: couldn't play
18 months: copies parents tasks
2years :ask for food drinks
3 yrs: could tell his full name and gender
5yrs: could help in household tasks but couldn't dress and undress
SPEECH DELAYED:
key language milestones all on time except mono and bisyllable words delayed
FAMILY HISTORY:
Significant family history present
Oblique transmission:From uncle
His uncle has history of seizures 10 years ago
DAILY ROUTINE:
He wakes up at 6 o clock and does his daily activities then he sees TV and cell phone and does small work at home .At 12 o clock he eats lunch if the curry is tasty and sometimes he skips his lunch .At 9 o clock he eats dinner and then he’ll sleep .
EXAMINATION
Patient is conscious and oriented
PR:68 bpm
BP:120/80 mmHg
RR:18 cpm
RS:BAE+ no added sounds
CVS: s1 and s2 heard no added sounds
Per abdomen:soft and non tener
Pupils:NSRL
GCS:15/15
UL. LL
Tone R. N. N
L. N. N
Power R. 5/5. 5/5
L 5/5. 5/5
CRANIAL NERVE EXAMINATION
Rt lft
I - sense of smell + +
II - visual acuity 20/20 20/20
color vision + +
III extraocular movements normal
IV - light reflex + +
VI accommodation reflex + +
Ptosis - -
Nystagmus - -
V sensory normal
Motor normal
Reflex
Corneal reflex + +
Conjunctival + +
Jaw jerk + +
VII Motor normal
Sensory normal
Reflex corneal + +
Conjunctival + +
VIII Rinnies positive positive
Weber Centralised
IX,X uvula Deviated to the left
gag reflex Absent
Palatal reflex absent
XI Trapezius and SCM good
XII Tone mild hypertonia
Wasting no
Tongue protrusion deviate to left
PROVISIONAL DIAGNOSIS:
seizures under evaluation
TREATMENT:
1.tab sodium valproate 500 mg po/od
2.tab oxcarbamazepine450 mg po/bd
3.tab phenytoin 100 mg po/od
4. watch for seizure episode
5. monitor vitals 4 th hourly 6. inform sos
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