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25 Y/F with headache and involuntary movements

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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   


11-08-2022


A 21 years old female P2L2 delivered 10 days back NVD - live male baby of 3.5kgs, housewife by occupation brought with complaints of 

*Headache since Morning 

*1 episode of involuntary movements at 12am


History of present illness 

Patient was apparently asymptomatic 1 day back then complained of headache since morning, 1 episode of involuntary movements pattern of tonic clonic seizure at around 12am today

H/o frothing from mouth 

No H/o tongue bite

No h/o involuntary micturition and defecation 

Episode lasted for 2 mins

Post ictal confusion present.


PAST HISTORY: Not a k/c/o DM,htn,tb,asthma,epilepsy 


PERSONAL HISTORY:

She is Married

She consumes 

Mixed diet 

Sleep is adequate 

Appetite normal

bowel and bladder movements are regular


MENSTRUAL HISTORY: 

Age at menarche:12 years

Cycle: 30/5 days, Normal flow.


OBSTETRIC HISTORY:

Age at Marriage:19 years

1st pregnancy: conceived after 1 month of pregnancy,NVD, 

2nd pregnancy: conceived after 6 months of 1st pregnancy NVD.


FAMILY HISTORY:

No similar complaints in family 




General examination:

On presentation: Patient conscious, coherent, cooperative, well oriented to time place and person.

Pallor present 

Vitals:

Bp:120/80

Pr:130bpm

Rr:24cpm

Temp:98.2f

Grbs:84mg/dl

Spo2:97%


SYSTEMIC EXAMINATION:

CVS:s1,s2 +

Rs:bae+

P/a: size of uterus:corresponding to 12wks 

CNS: b/l pupils NSRL

              R L

Tone: N. N

Power: 5/5. 5/5                  

Reflexes : B T S A K P 

               R: + + + + + Flexion 

               L : + + + + + Flexion

No neck stiffness 

Kernigs negetive 

Brudzinski negetive 

INVESTIGATIONS:




















DIAGNOSIS : Seizures under evaluation.

TREATMENT:

Presently: had a 2nd of episode of involuntary movement pattern of tonic clonic seizure at 1:15am lasted for 2 mins 

H/o frothing from mouth

No h/o tongue bite

No h/o involuntary micturition and defecation 

Post ictal confusion present.

Plan at the time of episode: 

2mg lorazepam IV

Levipill 25mg in 100ml NS IV

25 D IV

12-08-2022 

No fresh complaints, same treatment is given 

13-08-2022

The patient is absolutely fine 

The evaluation of seizure is ruled out to be pseudoseizure 



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