21 y/o woman with seizures
A 21 year old female with sudden onset b/l involuntary movements
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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.
Case-
A 21 year old female (obstetric score - P2L2A0), a resident of Narketpally, who is a housewife was brought to the OPD with the complaints of
- headache since yesterday morning
- an episode of involuntary movements at night 12 am
History of presenting illness-
The patient was apparently asymptomatic 1 day back then she complained of headache in the morning located in the middle part of skull for which she took medication but it didn't subside.
After having milk she slept and then at around 12 am she had an episode of involuntary movements (tonic- clonic type) of all limbs which lasted for about 3 mins.
Frothing +
No h/o tongue bite
No h/o involuntary micturition and defecation
She was then brought to our hospital. Post ictal confusion +
She had no memory of this event.
At about 1:15 am she had another similar episode tonic clonic pattern of involuntary movements which lasted for 2 mins.
For which she recieved the following treatment-
2mg lorazepam IV
Levipill 25mg in 100ml NS IV
25 D IV
Since today morning she has had a single episode of vomiting which is non-projectile, non-bilious and containing food particles.
Past history -
No h/o similar episodes in the past
She is not a k/c/o DM, HTN, TB, asthma, epilepsy, CAD, CVA
Family history -
No significant family history
Personal history-
She is Married
She consumes
Mixed diet
sleep is adequate
Appetite normal
bowel and bladder movements are regular
MENSTRUAL HISTORY:
Age at menarche:12 years
Cycle: 30/5 days, Normal flow.
OBSTETRIC HISTORY:
Age at Marriage:19 years
1st pregnancy: conceived after 1 month of pregnancy,NVD,
2nd pregnancy: conceived after 6 months of 1st pregnancy NVD.
FAMILY HISTORY:
No similar complaints in family
General examination:
On presentation: Patient conscious, coherent, cooperative, well oriented to time place and person.
Pallor present
Vitals:
Bp:120/80
Pr:130bpm
Rr:24cpm
Temp:98.2f
Grbs:84mg/dl
Spo2:97%
SYSTEMIC EXAMINATION:
CVS:s1,s2 +
Rs:bae+
P/a: size of uterus:corresponding to 12wks
CNS: b/l pupils NSRL
R L
Tone: N. N
Power: 5/5. 5/5
Reflexes : B T S A K P
R: + + + + + Flexion
L : + + + + + Flexion
No neck stiffness
Kernigs negetive
Brudzinski negetive
Investigations -
DIAGNOSIS : Seizures under evaluation.
TREATMENT:
Presently: had a 2nd of episode of involuntary movement pattern of tonic clonic seizure at 1:15am lasted for 2 mins
H/o frothing from mouth
No h/o tongue bite
No h/o involuntary micturition and defecation
Post ictal confusion present.
Plan at the time of episode:
2mg lorazepam IV
Levipill 25mg in 100ml NS IV
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