A 17 year old female with recurrent seizures

M.Vineela 

2k18

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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.

17 year female who is resident of Nakrekal came to causality yesterday evening (1 Dec 2022) with the complaints of 

Involuntary movements of both upper limbs and lower limb since 12 pm.

HOPI:

She was apparently asymptomatic till the age of 6 years then she developed fever with chills for 1 day .

The next day she developed involuntary movements of upper and lower limbs.

The last episode was today at 2 pm(2 Dec2022) which lasted for 30 minutes associated with uprolling of eye balls  followed by post ictal confusion,no micturition,no defection and no frothing from mouth.

She had history of headache and syncope.

She was taken to hospital at the age of 6 years then was admitted to the hospital and received medication and then she had the recurrent attacks even after medication frequently.

After the episode of seizures she had the recurrent falls which caused trauma to the head.

Few years ago when she was admitted to the hospital CT scan was done which revealed atrophy of right cerebral hemisphere. She has been on valproate .

After they visited other hospital as she was micturating following each seizure episode they started on tablet Lamotrigine.

After admission to the hospital from yesterday she had 5-6 brief episodes.

Past history:

No history of hypertension

No history of Diabetes

No history of CAD

No history of tuberculosis

No history of Asthma.

Personal history :

Her appetite was decreased since 1 week.

Has inadequate sleep since 1 month .

Bowel and bladder: Regular

Diet - mixed 

Addictions- none

She wakes up at 9 ,eats breakfast and she will do her daily activity. 

But since 1 month she was unable to perform.

She studied till LKG then stopped the school due to recurrent episodes.

Obstetric history:

Term baby

Birth weight 2.25 kg

Cried immediately after birth.

No hospital admission immediately after birth.

Achieved milestones according to her age.

Family history :

No relevant family history.

Treatment history:

Patient was on anti epileptic drugs from the age of 6 years.

General examination :

Patient is not conscious, coherent and cooperative not well oriented to time ,place and person.

No pallor, icterus,cyanosis, clubbing, lymphadenopathy, Edema.

Vitals:

Temperature: 98.6F

Pulse: 87 bpm

Respiratory rate :20cpm

Blood pressure:120/80 mm Hg

 

CNS Examination:

As she was not conscious , oriented to time, place and person

Her speech , behaviour and memory are not intact 

 

Sensory system:

Fine touch : not intact 

Pain : no sensation

Temperature: no response to heat or cold

Vibration: not intact

Two point discrimination test: absent

Motor system examination:

                 Right.                     Left

Tone       

Upper limb  normal.                Normal 

Lower limb normal.                  Normal

 Reflexes:

Biceps       2+.                            2+

Triceps.     2+                              2+

Supinator 2+.                              2+

Knee.         2+.                              2+

Ankle.         2+.                              2+

Power cannot be elicted as the patient is unconscious

Cerebellar function test:

Cannot be elicted

Gait cannot be elicted

Systemic examination

Cvs 

S1,s2 heard ,no murmur,apex beat at mid clavicular line at 5 th intercoastal space.

Respiratory system 

I: Chest bilaterally symmetrical, all quadrants

moves equally with respiration

P: Trachea central, chest expansion normal

P: Resonant

A: B/l equal air entry

B/I VBS

no added sound

Per. Abdominal examination :-

I normal

P soft non tender

No organomegaly

Investigations

Provisional diagnosis - GTCS known case of seizures since 10 years .

Treatment -

Injection- levipil 500mg IV bd

Injection - lorazepam 4mg IV 

Injection - optineurin 1ampoule in 100ml normal saline over 30 minutes

Injection - sodium valproate 500mg IV bd .