20 year male with recurrent seizures

 Hi, I am Yeddula Vishnu Priya, 5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's 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 elog also reflects my patient centered online learning portfolio

                                                             

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

20 male from Thummalagudem came to the hospital yesterday afternoon with chief complaints of

4 episodes of convulsions
4 AM 6 AM 7 AM 11 AM


HOPI

Patient had birth asphyxia and was taken to NICU
doctor observed an episode of mild convulsions
Patient was kept in the NICU for 8 days before discharging home

When patient was 6 months old he had and episode of high grade fever which was immediately associated with an episode of convulsion with uprolling of eyes but no frothing from mouth

They went to pediatric doctor and medications were given for 3 years
Apparently they used those medications for 6 months and then stopped using them
Then he was asymptomatic for few years
He was sent to school but he couldn't cope up with the students

When he was 7 years old he had an episode of seizures with uprolling of eyes but no foaming from mouth which lasted for less than a minute
then he fell during convulsions and had a head injury where swelling happened
Which recided and attained present size
Since then he was on medication and stopped attending school

Since then episodes occurred intermittently

2 days back then he had gone to his pare ts farm upon which he developed fever which was high grade and was associated with convulsions lasted for about 2 to 3 minutes, intermittent type and had uprolling of eyes and frothing from mouth
Post ictal confusion present for about 10 minutes
Cough present

PAST HISTORY
N/k/C of DM, TB, Asthma

Patient has h/o delayed milestones.

Patient is k/c/o epilepsy since the age of 7 years  

TREATMENT HISTORY

Tab. Sodium valproate 500mg PO/OD,
Tab. Oxcarbazepine 450mg BD,
Tab. Phenytoin 100mg OD. 

PERSONAL HISTORY
Single
Mixed diet
Loss of appetite
Normal micturition
Regular Bowel
No known allergies
Teetotaler

DAILY ROUTINE
6 am wakeup
7am tea
8 to 10 am breakfast
Comes to work
1pm lunch
10pm sleep

FAMILY HISTORY
his mother's brother has similar complaints since he was 16 years

BIRTH HISTORY
mother didn't have any contractions when she was 9 months pregnant
No movements were seen
LSCS was done but the baby didn't cry and was taken to the NICU and was kept there for 8 days
DELAYED MILESTONES SEEN

GENERAL EXAMINATION

In a well lit and adequately ventilated room with proper consent from patient's informant general examination was done
And patient was
Conscious and coherent
No pallor, icterus, cyanosis, clubbing of fingers, lymphadenopathy, pedal odema

SYSTEMIC EXAMINATION

CVS
S1 & S2 heard, no murmurs

RESP
Inspection- flat chest with a slight depression in the centre

Palpation - bilateral air entry present, normal vesicular breath sounds heard, no adventitious sounds

ABDOMEN
soft non tender , umblicus is everted, no scars and sinuses.

CNS

Tone                         UL                  LL

 - upper limb          subtle hypertonia

 - Lower limb     subtle hypertonia

Power 

- upper limb    5/5                       5/5 

- Lower limb 5/5                      5/5     


Reflexes

 - knee jerk  + +

 - Ankle jerk + +

 - Biceps + +

 - triceps + +

 - Plantar normal normal 

hyperreflexia seen

CRANIAL NERVES EXAMINATION
                                                     Rt                lft
I - sense of smell                       +                   +

II - visual acuity                      20/20         20/20
      color vision                           +                +

III   extraocular movements        normal
IV - light reflex                           +                  +
VI   accommodation reflex      +                  +
       Ptosis                                     -                   -
       Nystagmus                           -                   -

V  sensory                                        normal
    Motor                                           normal
   Reflex
Corneal reflex                              +               +
Conjunctival                                 +               +
Jaw jerk                                         +               +

VII  Motor                                          normal
       Sensory                                       normal
        Reflex     corneal                    +               +
                         Conjunctival           +              +

VIII  Rinnies                       positive   positive
Weber                                       centralized 

IX,X uvula                    deviated to the left
         gag reflex                Absent
          Palatal reflex          absent

XI   Trapezius and SCM        good
XII    Tone                           mild hypertonia
          Wasting                          no
          Tongue protrusion      no deviation

INVESTIGATIONS