1st September 2022
This is online E log book to discuss our patient’s de-identified health data. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients’ clinical problems with collective current best evidence-based inputs.
This e-log book also reflects my patient centred online learning and your valuable inputs on comment box is 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.
A 35 year old male came with chief complaints of seizures which lasted for 30 minutes.
History of present illness:
Since childhood - patient had developmental delay and delayed milestones.
5 years ago - similar complaint of seizure which lasted for 5 minutes and subsided after consulting a local doctor. And not on any medication since then.
Patient was apparently normal 3 days back and developed involuntary, generalized, to and fro movements of upper limbs and lower limbs which lasted for half an hour.
The episode is associated with upward rolling of eyeballs and frothing.
Patient has not regained consciousness for half an hour during the episode of seizure.
No history of tongue bites during the episode of seizure.
No history of fever, headache, vomiting and giddiness.
Past history:
No history of DM and hypertension
Patient is a known case of cerebral palsy.
Personal history:
Not married due to developmental delay.
Appetite - normal
Mixed diet
Bowel habits - regular
Micturition - normal
No allergies and addictions
Family history:
Not significant.
General Examination:
The patient was conscious, coherent but not co-operative and not well oriented to time, place and person.
Normally built and nourished.
Pallor absent
Icterus absent
Cyanosis absent
Clubbing absent
Edema absent
Lymphadenopathy absent
Vitals:
Temperature - afebrile
Pulse rate- 86/min
Respiratory rate- 14/min
Bp- 100/70 mm hg
SpO2- 98%
Systemic examination:
Cardiovascular system- no thrills and murmurs, S1 and S2 heard.
Respiratory system - normal vesicular breath sounds heard.
No dyspnea and wheezing.
Abdomen - shape- scaphoid, no tenderness.
Central nervous system-
Tone is increased in both upper and lower limbs.
Power is 3/5 in all four limbs.
Provisional diagnosis:
Generalized tonic seizures
Status epilepticus?
Known case of cerebral palsy.
Investigations :
Treatment:
IV fluids - 100ml/ hr
Inj levipil- bd (500 mg - x - 250 mg).
Inj monocef - 1gm / iv / bd
Inj pan - 40 mg / iv / od
Inj zofer- 4 mg iv
Inj loraz- 2 cc/ iv
Inj optineuron - 1 amp in 100 ml ns /iv
Tab dolo - 650 mg
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