159 Ravali Irugurala

GENERAL MEDICINE 


18 yr old female with seizures 

This is an online E logbook 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 an available global online community of experts to solve those patients 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 are welcome.

I’ve 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.

Following is the view of my case :

Date of admission : 12/11/22

18 yr old female came to the opd with 

Chief complaints:

Of seizures and loss of consciousness At 10:30 PM On 12/11/22

HOPI:

18 yr Old was apparently alright till yesterday night ,while  she was watching tv, she suddenly developed  involuntary movement of 4 limbs associated with frothing, uprolling of eye balls which lasted for about 1-2 mins followed by post ictal confusion which is for about 5 minutes,No c/o involuntary micturition,tongue bite was present.

No aggrevating or relieving factors.

No associated symptoms present.


PAST HISTORY:

K/c/o Hypothyroidism 2 yrs back(stopped using medication since 1 year)

H/o PCOD 1 yr back

N/k/c/o DM , hypertension, asthma, epilepsy,TB, CAD,CVA.

FAMILY HISTORY:

Not significant.

PERSONAL HISTORY:

Diet - mixed 

Appetite - normal

sleep - adequate

Bowel and Bladder movements -regular

Addictions - no

No known allergies

DRUG HISTORY:

No significant drug history.

GENERAL EXAMINATION:

Patient is conscious ,coherent, cooperative and was well oriented to time, place and person .

At the time of examination.

She is examined in a  room, with consent taken.

She is moderately built and well nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent.

VITALS:

Pulse rate - 84 bpm

Respiratory rate - 16 cpm

Blood pressure - 120/70 mmHg

SpO2 - 98% on Room air

GRBS - 117mg/dl

Temperature: Afebrile.

SYSTEMIC EXAMINATION:

CVS : S1 and S2 heart sounds heared

NO murmurs and thrill

RESPIRATORY SYSTEM : Bilateral air entry present             

position of trachea - central 

Vesicular breathsounds heard.

CNS : No focal deficits are found.

ABDOMEN :

Soft

Non tender

No palpable mass

 Bowel sounds heard

 NO organomegaly .

Provisional diagnosis:

seizures under evaluation.

Investigations:

MRI brain plan with epilepsy protocol:


Serum electrolytes:


Serum calcium:

serum magnesium:













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