34 year Old male with seizures

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

Hopi:
Patient was apparently asymptomatic 3 days back then he developed generalized movements of upper limbs and lower limbs for which he was brought to the hospital and seizure episode lasted for 40minutes with uprolling of eyeballs and frothing

No h/o tongue bite.

No regained consciousness during seizure episode.

No h/o fever, giddiness, headache, vomiting. 


Past history:  

Similar complaints in 8yrs back and is not on any medication.

Not a k/c//o DM HTN TB CAD and asthma 

Family history: 

Not significant 

General examination: 

Patient is c/c/c 

Temp: 98.6F

BP: 100/70mmhg

PR: 86bpm

RR: 14cpm

  pallor present

No icterus 

No cyanosis 

No clubbing 

No lymphadenopathy 

No edema 

Systemic examination: 

CVS :S1 S2 sounds heard 

RS: BAE+,clear

P/A: Soft and non tender  

CNS: no speech
Memory:intact
Behaviour:normal 
Reflexes- 

Tone increased in all 4limbs.











USG

 
2D-ECHO



Chest x-ray 




Hemogram 29/08/2022


Hemogram 30/08/2022


RBS:79mg/dl 

Serum creatinine:0.7mg/dl





Diagnosis:

Generalised tonic seizures

K/c/o cerebral palsy 


TREAMENT:-

1. IV fluids NS,RL @100 ml /hr.

2.INJ.LEVIPIL 1gm IV/stat->500mg IV/BD

3.INJ .monocef 1gm IV/BD

4.INJ.PAN 40 mg IV/OD

5.INJ.ZOFER 4mg IV/soa

6.INJ.LORAZ 2cc IV/sos.

7.INJ.optineuron 1amp in 100ml NS IV/OD

8.TAB.DOLO 650 mg sos



























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