25 YRS OLD MALE WITH SEIZURES
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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.
CASE:
25 yr old male resident of devarakonda farmer by occupation came to general medicine OPD with chief complaints of an episode of seizure 25 days back.
HOPI:
Patient was apparently asymptomatic 13 years back then he developed an episode of seizure which is sudden in onset ,it started as dragging type of pain in his right hand ,radiating upto his shoulder ,the pain is so severe that he feels like Someone is twisting and chopping off his hand associated with jerky movements of that hand then he fell unconscious,the whole episode lasted for 3-5 minutes, associated with tongue biting.
Not associated with frothing from mouth, uprolling of eyes , postictal confusion,and autonomic symptoms like urination and passage of stools during seizure episode.
After the first episode he took some ayurvedic medicine for 2-3 months but he got another similar episode of seizures ,then he went for another ayurvedic medicine and used it for 2 months but he again experienced similar episode,after these 3 episodes he came to kamineni hospital .
In kamineni hospital they diagnosed it as Right complex partial seizures and gave Tegretol and
Zincovit ,he continued to use this medication for 3 years with regular follow up of once in three months .He stopped the medication by himself without any advice From his doctor .
After this 12 years of seizure free period he got 4 th episode 25 days back .
On the day of 4th episode he woke up at 7 o clock and ate rice at 9 o clock went to farm to work ..at around 12 o clock he climbed palm tree for toddy extraction but he felt a bad aura that he is going to have seizures as some pain started in his right hand then he immediately came down and sat in a safe place ,then same like first episode he experienced dragging type of pain which is increasing as it radiating to shoulder as if his hand is chopped off from his body ,with jerky movements followed by period of unconscious .There were no one around him at that time of incident ,he regained his consciousness and went home ,after two days went to rmp doctor he gave an injection and tablets ,due to financial problems he didn't visit hospital immediately after seizure episode .
History of intake of pork meat 6 months back.
And excessive alcohol intake 3 days before the seizure episode.
No history of fever , neck stiffness,vomitings,headache.
DAILY ROUTINE:
He daily wakes up at 7'0 am , eats rice at 9'0 am after eating he goes to work in their farm , usually they cultivate paddy and Cotton ,
He eats lunch at 1:00 pm and again work in the field upto 5:30 or 6:00 ,after work he will go to home and fresh up and goes out with his friends and drinks 2-3 beers once in 3 days then he eat something and goes to bed , usually sleeps around 10 pm.
Past history:-
History of truma to head when he is 1 month old ,he fell down from the bed .
Not a know case of diabetes mellitus, hypertension,tb, asthama, thyroid disorders.
Personal history:-
Diet :- mixed
Appetite:- normal
Sleep :- adequate
Bowel and bladder movements:- regular
Addictions :- drinks 2-3 beers once in 2 days .
Family history:-
Similar complaints observed in his elder sister when she is 12 years old but didn't recurred after taking ayurvedic medicine.
No other family members have any significant history
GENERAL EXAMINATION:
Patient is conscious,coherent and co-operative.well oriented to time,place and person.
Moderatly build and moderatly nourished.
No pallor, icterus, cynosis,clubbing, lymphadenopathy ,edema
Vitals:-
BP:140/90(lft arm)
PULSE RATE:82/min
RESPIRATORY RATE:20cycles/min
TEMPARATURE:afebrile
* CNS EXAMINATION:
Right handed person
HIGHER MENTAL FUNCTION
Counsious ,oreinted to time place person
Speech normal
Behaviour normal
Memory intact
Intelligence normal
CRANIAL NERVE EXAMINATION
-OLFACTORY-normal
- optic : normal visual field
-oculomotor,trochlear,abducens facial-intact
- vestibulocochlear- intact
- glossopharyngeal -intact
- vagus-intact
-accesory spinal ganglion nerve intact
- hypoglossal intact
Sensory system:
-fine touch: intact
-pain: normal
-temperature - normal
- vibration -normal
-stereognosis- normal
-two point discrimination-present
Motor system examination
Nutrition -
U/L. R. L
Normal. Normal
L/L. Normal. Normal
TONE:
U/L. R. L.
Normotania. Narmotonia
L/L
Normotonia. Normotonia
POWER. :- RIGHT. LEFT.
SHOULDER
flexion : 5/5 5/5
Extension 5/5. 5/5
Abduction 5/5. 5/5
Adduction 5/5. 5/5
Internal rotation 5/5. 5/5
External rotation 5/5. 5/5
Elbow:5/5. 5/5
Flexion. 5/5. 5/5
Extension:5/5. 5/5
Wrist:5/5. 5/5
Flexion:5/5. 5/5
Extension:5/5. 5/5
Abduction : 5/5. 5/5
adduction:5/5. 5/5
Hip
Flexion:5/5. 5/5
Extension. 5/5. 5/5
Abduction:5/5. 5/5
Adduction 5/5. 5/5
Internal rotation:5/5. 5/5
External rotation. 5/5. 5/5
Knee 5/5. 5/5
Flexion 5/5. 5/5
Extension. 5/5. 5/5
Ankle. 5/5. 5/5
Plantarflexion:. 5 /5. 5/5
Dorsiflexion. 5/5. 5/5
Toe. 5/5 5/5
Movements:5/5
REFLEXES:
-Corneal present
-Conjunctival present
-Abdominal: present
-Plantar: present
https://youtube.com/shorts/trJEVaQ847s?feature=share
*DEEP REFLEXES:
Biceps : 5+. 5+
Triceps 5+. 5+
Knee : 5+. 5+
Ankle: 5+. 5+
https://youtube.com/shorts/b9-7viblx1s?feature=share
CEREBELLAR
-NYSTAGMUS absent
-DYSADEADOCHOKINESIA absent
https://youtube.com/shorts/PORgwEFtKAI?feature=share
-FINGER NOSE tip- normal
Rhomberg sign
Rebound phenomenon present
Heel to knee intact
Gait :- normal
https://youtube.com/shorts/kpc5bJPC-4E?feature=share
Meningial sign
Kernigs sign negative
Brudzinski sign negetive
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:
25/11/2022:
28/11/2022:
DIFFERENTIAL DIAGNOSIS:-Right hand complex partial seizures due to old calcified granuloma in right basal ganglionic region.
-Neurocysticercosis
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