A 35 year old male with the k/c/o Epilepsy

8/12/2023

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Sanidha Singh 

Roll no.- 98

Unit 4

CHIEF COMPLAINTS:

Complaint of involuntary movements of both upper limb and lower limb since morning.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic till morning then he had sudden involuntary movements tonic clinic of both upper limb and lower limb for about 30 mins associated with drooling of saliva, up rolling of eyes.

 No involuntary micturition or defecation. 

Post ictal confusion present.

2 episodes of seizures within 1 hour gap.

No headache, chest pain.

No vomiting, loose stools.

No fever.

PAST HISTORY:

K/C/O epilepsy since childhood on Tab. Phenytoin 100 mg OD

N/K/C/O hypertension, diabetes mellitus, thyroid 

PERSONAL HISTORY:

Diet:Mixed 

Appetite: normal 

Sleep: adequate

Bowel,bladder:regular movements.

Addictions: Occasional Alcoholic 

FAMILY HISTORY : Mother is on k/c/o hypertension and is on medication since 1 year.

Not allergic to any drugs. 

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent,cooperative,well oriented to time,place,person. He  is moderately built and nourished.

No signs of pallor, icterus, cyanosis, clubbing, lymphoedenopthy, oedema. 

Vitals:

PR- 112 bpm

RR- 16 cpm

BP-140/90mm hg

GRBS- 112 mg/dl

Temp- 98.4 F

SYSTEMIC EXAMINATION:

PER ABDOMEN: Soft, non tender and no organomegaly 

RESPIRATORY SYSTEM: BAE + , NVBS + , No added sounds 

CVS: S1 S2 + , No murmurs.

CNS: 

Tone- 

            R               L

UL        N              N

LL         N              N

Power- 

              R               L

UL         5/5            5/5 

LL          5/5            5/5

Reflexes- 

                R                 L

B             +2              +3

T              +2              +3

S              +1              +2

K              +2              +2

A               +2              +2

P                F                F

INVESTIGATIONS: 

MRI Brain Plain with Epilepsy protocol done on 7/12/23:

Impression: No abnormality detected in brain.

Bilateral hippocampi normal.

2 D Echo done on 8/12/23: 

No RWMA

Mild TR; No MR/AR

No AS/MS, IAS- Intact

EF= 63, RVSP= 32+ 10 = 42 mmHg

Good LV Systolic function

No diastolic dysfunction.

IVC size (1.29cms) collapsing

No PAH/ PE/ LV clot.

TREATMENT:

INJ. LEVIPIL 500 MG IN 100 ML NS 12TH HRLY 

INK. LORAZEPAM 2CC (4MG)  IV/ SOS 

IV FLUIDS NS @ 50ml/hr 

INJ OPTINEURON 1 Amp in 500 ml NS IV/OD

TAB. ULTRACET BD 

ZYTEE GEL L/A