60YR OLD FEMALE WITH FOCAL SEIZURES

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Name : Supriya .K ( Intern ) 

Roll Number : 63 

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. 

60YR OLD FEMALE PATIENT, RESIDENT OF RAMANAPET,FARMER BY OCCUPATION, CAME TO THE OPD,WITH THE CHIEF COMPLAINTS OF : 

C/O Involuntary movements of Lt UL and LL  , associated with frothing ,Uprolling of eyes ,Tongue Bite ,Post Ictal Confusion present for 10 minutes .

Tongue Bite : 

No seizure activity at presentation but H/O two episodes of seizures occured at their home place and at their local Hospital ( at Ramanapet).First it started in the left upper limb and then progressed to left lower limb .

 Fever ,which is Sudden in onset and intermittent type  since 2 days associated with chills ,rigors  and head ache 

Neck pain- dragging type ,diffuse ,present since 2days 

H/O fall from bike 2years ago , led to mild abrasions over body and head  and associated with fracture of LT wrist joint (as she fell over left side -one side) .

No H/O Cold ,Cough , loss of appetite, Diurnal Variation , Burning Micturition 

PAST HISTORY: 

Not a K/C/O HTN, DM II , Epilepsy,Asthma ,TB , CAD ,CVD ,Thyroid 

PERSONAL HISTORY : 

Appetite -Normal 

Diet - Mixed 

Sleep - adequate

Bowel and bladder movements -Regular 

Addictions: Occasional alcoholic ( once every 3days - she consumes 90ml of alcohol )

Betel Nut chewing - Daily for 5-6 times 

Allergies : No allergies 

GENERAL EXAMINATION: 

Patient is conscious ,coherent , cooperative, Moderately Built and Moderately Nourished .

Temp: Afebrile 

BP : 130 / 90 mmHg 

PR : 87bpm 

RR : 20cpm 

SPO2 : 96 %

GRBS : 155 mg/dl 

Pallor : absent 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent 

SYSTEMIC EXAMINATION: 

CNS : HMF +  

                  RT                    LT 

Tone : UL : N                    N

             LL : N                    N

Power : UL -5/5                5/5

               LL- 5/5                 5/5 

Reflexes : biceps: 2+            2+

                Triceps : 2+           2+

                   Knee:   2+            2+

                   Ankle : 1+            1+

             Supinator : 1+           1+

              Babinsky : plantar       plantar 

                                  Flexion        flexion 

CVS  :   S1 S2 + ,no murmurs 

RS :  BAE Present 

P/A : Soft and Non tender 

Meningeal signs like : neck stiffness , kerning sign,brudzinsky sign are negative 

INVESTIGATIONS: 

MRI BRAIN  REPORT: 

-Acute Infarcts in Right  Precentral Gyrus ,Pre motor area ,middle frontal gyrus ,centrum semi ovale ,Corona Radiata 

- Mild  diffuse  Cerebral atrophy 

2D ECHO : 

PROVISIONAL DIAGNOSIS: 

LEFT FOCAL SEIZURES WITH  SECONDARY GENERALISATION ,ACUTE ISCHEMIC CVA

(HYPOKALEMIA)

MANAGEMENT: 

Inj . Levipil 500mg IV /BD  in  100 ml NS

 Tab . Ecospirin gold AV 75/10 mg PO /OD /HS 

Tab . Dolo 650 mg PO/ TID 

Inj PCM 1gm IV / SOS ( if temp > 101°F ) 

Temperature Monitoring 4th Hourly 

Vitals Monitoring 6th hourly 

SOAP NOTES: 

ICU 

DAY -2 

BED -6

UNIT -3 

S

No fever spikes 

Giddiness + 

Tongue Numbness + 

O 

Patient is Conscious ,Coherent , Cooperative

Temp : Afebrile 

BP : 110 /80 mmHg 

PR : 76bpm 

RR : 18cpm 

GRBS : 

2AM - 135 mg/dl 

8AM - 123 mg/dl 

CVS : S1S2 + 

RS : BAE + 

CNS: NAD 

SPO2 : 99%

I /O : 1000/300 ml 

A 

LEFT FOCAL SEIZURES WITH 2° GENERALISATION 

,ACUTE ISCHEMIC CVA ( HYPOKALEMIA) 

P 

IV Fluid 1. NS with OPTINEURON 1amp IV /OD 

Inj KCL 2 amp in 500 ml NS IV/STAT Over 5 hours 

T. Levipil 500mg IV /BD

T . Ecospirin gold 20mg PO/OD/HS 

T. Dolo 650mg PO /SOS 

Syp . Potchlor 10ml PO/TID 

Zytee Lotion L/A 3times a day 

Temp Monitoring 4th hrly 

Vitals monitoring 6th hrly

 

WARD 

DAY -3

UNIT -3 

S

No fever spikes 

Tongue Numbness + 

O 

Patient is Conscious ,Coherent , Cooperative

Temp : Afebrile 

BP : 120 /90 mmHg 

PR : 76bpm 

RR : 18cpm 

GRBS : 104 mg/dl 

CVS : S1S2 + 

RS : BAE + 

CNS: NAD 

SPO2 : 99%

I /O : 2000/ 1200 ml 

A 

LEFT  FOCAL SEIZURES WITH 2° GENERALISATION 

(HYPOKALEMIA) 

P 

Inj Optineuron in 500ml NS IV /OD 

T. Levipil 500 mg PO/BD 

T . Ecospirin gold 20mg PO/OD/HS 

T. Dolo 650mg PO /SOS 

Syp . Potchlor 10ml PO/TID 

Zytee Lotion L/A 3times a day 

Temp Monitoring 4th hrly 

Vitals monitoring 6th hrly

WARD 

DAY -4

UNIT -3 

S

Head ache +

Tongue Numbness + 

No fever spikes 

O 

Patient is Conscious ,Coherent , Cooperative

Temp : Afebrile 

BP : 130 /80 mmHg 

PR : 78bpm 

RR : 18cpm 

GRBS : 104 mg/dl 

CVS : S1S2 + 

RS : BAE + 

CNS: NAD 

I /O : 2000/ 1200 ml 

A 

LEFT FOCAL  SEIZURES WITH SECONDARY GENERALISATION ,ACUTE ISCHEMIC CVA 

(HYPOKALEMIA) 

P 

Inj Optineuron in 500ml NS IV /OD 

T. Levipil  500 mg PO/BD 

T . Ecospirin gold 20mg PO/OD/HS 

T.Dolo 650mg PO/TID 

Syp . Potchlor 10ml PO/TID 

Zytee  Lotion L/A  3times  a day 

Temp Monitoring 4th hrly 

Vitals monitoring 6th hrlyLth hrlyL SEIZURES WITH 2°