18 YR OLD FEMALE WITH H/O FALL AW LOC

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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. 

18 YR OLD FEMALE, CAME TO OPD WITH 

H/O Fall associated with loss of consciousness (last episode - 15days ago ) 

H/O Fever since 15 days 

Patient was apparently asymptomatic 3YEARS ago ; 

SEQUENCE OF EVENTS ,WHICH LEAD TO THE PRESENT CONDITION: 

(BIOLOGICAL COMPONENT) : 

In 2019YEAR - 3years ago - at the age of 15years (During her 10th Class ) - She had Irregular Menstrual Cycle , where her Cycle lasted for one month duration and used 4Pads /day for one month continuously ,Not associatied with clots 

After 1 month of heavy menstruation ,She didnt menstruate for 6months .After this 6months ,She had her cycle with 10 days of menstruation .Then ,her Cycle got regularised (28 days )with 5-7days of Menstruation/Cycle ,used 2pads /day .Not associatied with Clots and Spotting .

She was not on any Medication for Irregular Menses .( Cycle got Regularised on its own ) 

(Menstrual History- Age of Menarche -13years -in 8th Class - Regular ,28days Cycle - 5 days /Cycle ,used 2Pads /day ) 

IN FEB 2022 - During Her Intermediate -She used to Stay in Hostel - One day, her hostel building was painted - (According to Patient : On exposure to Paint smell )- She developed Breathlessness associated with Chest pain and that lead to Fall with weakness of 4limbs ,Uprolling of eyes -Present , Consciousness -Intact during this episode ,which lasted for 30 minutes .After episode ( blurring of vision lasted for 10mints ) 

H/O decreased intake of food ,Despite of Normal appetite ( due to Hostel food -acc to Pt)

No H/O Vomitings , Seizures episode ,Tongue bite ,Frothing ,Clenching of fist ;went to Hospital @ Nalgonda ,there On investigations : Hb- 6.5gm% , RBC -3.2millions/cumm , Chest X ray -Normal, took medication (IFA , Inj Fe Sucrose was given ) .

( H/O Frequent Syncopal attacks @ nearly 20times ,including last episode ,which happened 15days ago 

Feb 2022 to Dec 2022 --> H/O Fall nearly 10times ---->Consciousness intact 

Dec 2022 to Feb 2023 ---> H/O nearly 10times --->loss of Consciousness present 

IN JUNE 2022 (6 Months ago) : H/O Lower back pain ,which was insidious in onset ,gradually progressive, non - radiating lasted for 30mints -- only one episode -- Relieved on taking medication - Never recurred again .

IN NOV 2022 (2 Months ago) : She developed severe head ache over temporal region ,radiating towards parietal region (explained as Upwards by patient ) ,pain increased on exposure to loud sounds and also associated with aggression which lead to Suicide attempt due to unbearable pain ( as she thought , death is the best choice over suffering this pain ) . --------- went to Psychiatrist , her thoughts vanished ,head ache was not relieved .

On December 15th 2022 ----> She went to hospital at Gollegudem i/v/o H/O Fall a/w loss of consciousness, Fever and head ache (got relieved on taking medication) 

fever - which was low grade , associated with chills and rigor ,Sudden onset ,Intermittent type.

not relieved on taking medication.

(there in hospital @ gollegudem - she was referred to Psychiatrist i/v/o previous H/O suicidal thoughts -despite of having nothing on presentation and was given medication again ) .

H/O weight gain since 6 months (upto 10kgs ) 

Family History : Her Mother had one episode of seizure ( during her Pregnancy -in 5th month )used medication from 5th month of Pregnancy for 3years .She is Single Child .No sibilings .

 

             

PERSONAL HISTORY: 

Appetite - Normal 

Diet - Mixed 

Sleep - adequate 

Bowel and Bladder movements - Regular 

Addictions - No addictions

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: 

FEVER CHART: 

PROVISIONAL DIAGNOSIS: 

? SEIZURES UNDER EVALUATION 

? VASO VAGAL SYNCOPE 

? SOMATIZATION DISORDER 

MANAGEMENT: 

TAB LEVIPIL 250MG PO/BD 

TAB MVT PO /OD 

PSYCHO SOCIAL COMPONENT: 

Every line of her Story is Responsible for her Presentation : 

She is a 18YR Old female, who is a Student by Occupation (Graduation 1st year ), Her Mother is Daily wage worker by occupation ,She is a Single Parent ,as Her Father abandoned them during her Childhood and started living with other family ,where he has one son . She has no Siblings ,as she is a single child , she grew up as a Mother's Little Princess ,She is a Stubborn girl and doesnt obey her Mothers words and She usually hate her Father ,as he left them and living seperately but he visits their home occasionally along with his another Family. 

Her Mother is the Only Person ,who works for their family and raising her daughter with her Savings .

She was Staying in hostel since her Childhood (4th Standard) , She has many close friends . She was into Relationship 3YEARS ago (From 9th Standard) with her Senior . They were in deep relationship, 1 YEAR ago he suddenly said Break up ,like he doesn't want to Marry her ,She completely gone mad and thought ,Who was he to say break up to me,like ,i will say break up to him rather .

He tried manyways to convince her but she refused to listen to him all the time , he used to come near her hostel and Showed her that he will die for her , by cutting his hand with knife and literally begged her to come back into Relationship but she completely avoided him .Finally , after many Struggles ,he married to another lady 7 months ago .

She had exposed her Relationship to her Mother ,as she doesnt want to hide anything from her Mother . Her Mother Scolded and beat her soo much during her initial days of relationship but she never listened to her mother .

She spends most of the time on Phone (mobile addiction -present) , interacts less with the Relatives 

She has a guilt of loosing Her Boyfriend (Nice guy - according to Pt ),as She love him the most but she said break up out of her foolishness and by the time ,she was realized ,he was married to another lady .

She attempted Suicide 4 times - one for him , another for her close friend (girl) -(as her friend became emotional on knowing about her Suicide attempt and She did - Later again Pt did ) , another 2 attempts - done because of her Mother (after small disputes ).

Guilt of Suicide attempt - Present 

MY OBSERVATION DURING HOSPITAL STAY : She is a Stubborn girl ,who doesnt obey her Mother words but loves and Cares her sooo much ( How I observed ? ----------- She wont let her mother to take decisions ,She takes her own decisions and doesnt obey her mother words - with regarding any aspect during hospital stay ) ,when we went for investigations , She always cared about her Mother like you will get body aches ,dont roam with me ,take rest like stay there only in the ward . 

She has so many Friends ,with whom She shared financial crisis .( Not only family members,she pinged her friends also for money , regarding hospital stay).

MY VIEW OVER THIS CASE - She is a INNOCENT adolescent girl (teenager ) , who has No Siblings to share her thoughts and emotions , She has many friends but of same age group (lack of maturity ) , as she is stubborn and affectionate daughter to her mother , she never cared her words and has less interaction with her Relatives ,as she spends most of her time on mobile and friends .

Ruling Out ORGANIC CAUSE through her Investigations (MRI ,EEG ,2D ECHO ) , can be considered as under Psychiatric Case BUT 

Ruling Out DYSFUNCTIONALITY - I dont want to label My 18 YR Old patient (Teenager ) with any kind of Mild /Moderate /Severe Depression and Dissociative Disorder.

According to me ,She just Need Moral Support ,that can be Obtained through Counselling and Psychotherapy sessions .

(During Conversation - Eye to Eye Contact maintained , PMA - Normal 

Self - Hygeine maintained ) 

       I AM  RELATING MY  CASE  TO  PNI - PSYCHONEURO IMMUNOLOGY ( through application of BioPsychoSocial Model )