70 y/o F with seizures

70 y/o woman with seizures 

Manvi Sharma 

Roll no 88 

Batch 2018

Date : 14-3-22 

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box."

Chief complaints - 

A 70y/o female who is an anganwadi ayamma presented to the casualty with c/o of two episodes of seizures since morning 

History of presenting illness -

The patient was apparently asymptomatic till today morning and then at around 12 pm she had an episode of fits characterized by involuntary movement of both lower limbs in association with frothing at mouth and tongue bite. It was sudden in onset and without any preceding aura. 

She experienced another episode of fits in the similar manner at around 2pm after having toddy and taking rest. This episode was longer than the first one, lasting for about 10 mins. It was followed by post ictal confusion for 15 mins. 

No c/o involuntary micturition and defecation 

No c/o limb weakness and headache 

Past history- 

Not a k/c/o DM, HTN, epilepsy, CAD, asthma, TB 

Personal history -

Appetite - normal 

Diet - mixed 

Bowel & bladder movements - regular 

Addictions - drinks toddy ocassionaly 

She goes to the nearest anganwadi centre and does the work of an ayamma from morning 8 to evening 4 and then comes back home. 

Family history -

Not significant 

Vitals (on admission) -

Temp - afebrile 

BP- 130/70 mmHg 

PR- 80 bpm 

RR- 16 cpm 

GRBS - 135 mg/dl 

General physical examination -

The patient is conscious, coherent and cooperative and well oriented to time, place and person. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema 

Systemic examination -

CVS - S1, S2 heard , no murmurs 

Respiratory system- BAE+, NVBS heard 

GIT - scaphoid shape, soft and non- tender, no organomegaly 

CNS - 

E4, V5, M6

B/l pupils NSRL

Tone - UL - N

          - LL - N 

Power - UL - N 

            - LL - N 

B/l plantar - mute 

Investigations- 

CBP- 

Hb - 10.5 g/dl 

TLC - 12,400 

Neutrophils - 89

Lymphocytes - 6

Eosinophils - 2 

Monocytes - 3 

Platelets - 2.25

CUE -

ALB - trace 

Pus cells - 2 to 4 

RFT -

Urea - 24mg/dl 

Creatinine - 0.8mg/dl 

Uric acid - 3.6mg/dl 

Calcium - 9.5mg/dl 

Phosphorous - 2.9mg/dl

Sodium - 140mEq/l

Potassium - 3.6mEq/l

Chloride - 99mEq/l

LFT- 

TB- 0.52mg/dl

DB- 0.16mg/dl

AST- 32IU/l

ALT- 14IU/l

ALP- 150IU/l

TP- 6.9g/dl

ALB- 4.3g/dl 

A/G - 1.68

ABG- 

pH - 7.407

pCO2 - 29.9mmHg

pO2 - 87.9mmHg

O2 sat- 95.6%

Na+ - 136mmol/l

K+ - 3.0mmol/l 

Ca2+ - 0.78mmol/l

Cl- - 102mmol/l

HCO3-(std) - 20.5mmol/l

HCO3-(cal) - 18.5mmol/l

ECG -

2D ECHO-

MRI -

Diagnosis- seizures (EEG report awaited) 

Treatment- 

INJ LEVIPRIL 500 mg IV BD

INJ PAN 40 mg IV OD 

INJ OPTINEURON 1 amp in 100 ml NS IV OD 

INJ ZOFER 4mg IV BD  

Monitoring vitals 

Advice at discharge - 

TAB LEVIPRIL 500mg PO/BD

TAB PAN 40 MG PO/BD

TAB MVT PO/BD 

Follow up - Review in GM OPD