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30 year old female with seizures

191 Hitesh 


This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians 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 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.


38 YR OLD FEMALE CAME WITH THE C/O SEIZURES SINCE 4 DAYS .


Patient was apparantly asymptomatic 20 days back then she had fever , headache , cough , cold for which she had taken treatment from the local hospital , from then she had on and off fever with generalized wekness and 4 days back she had slurring of speech for which she went to a local hospial and there she had episode of seizure involving right upper limb and deviation of mouth , associates with tongue bite ,episode lasted for 5 min . No H/o loss of consciousness , involuntary micturition , involuntary defecation . Again 6 more episodes of right upper limb unilateral focal seizures on the next 3 days that is 2 episode each night .from there she was referred to our hospital for further treatment .


PAST HISTORY 

K/C/O poliomyelitis since 3 years of age (5 -10 days post vaccination)

Not a k/c/o DM , HTN , CAD , ASTHMA , TB .

Underwent surgery for removal of ? Lipoma  8 years ago .


PERSONAL HISTORY 

Married 

Occupation :Tailor ( sweing with hand )

Diet : mixed

Appetite : decreased

Bowel and bladder : Regular 

No addictions .

No known allergies .


FAMILY HISTORY 

No K/C/O HTN , DM, ASTHMA , THYROID , TB , EPILEPSY in the family .


MENSTRUAL HISTORY 

- Age of menarche : 12 years 

- Regular cycles , 4-5 days bleeding for every 30 days .

No pain and No clots 

No c/o heavy menstrual bleeding .


MARITAL HISTORY

Age at time of marriage - 28 years 

Age of her husband at time of marrige - 32 years .

Non consaguinous marriage.

Marital life - 9 years .

Both patient and her husband used  some herbal medications for a week for infertility two years after marriage and later they did not 

Use any medications for infertility.

Patient husband is k/c/o diabetic since last 1 year and not on any medication .


 DAILY ROUTINE

She was homemaker and wakes up daily at 6 am in the morning followed by daily chores and eats breakfast (rice with curry) and then countinues her daily household work and takes lunch around 2-3 pm. Later she finishes the works which were pending in the morning and then have her dinner around 7:30 pm and sleeps aorund 8:30 - 9 :00 pm.


GENERAL EXAMINATION 

Patient is conscious , cooperative 

No Pallor, icterus ,cyanosis, clubbing , lymphadenopathy , edema.

VITALS 

TEMP : 98.6

BP : 120/ 80 mmhg

PR : 92/ min

RR : 20/ min 

Spo2 : 98% on RA


SYSTEMIC EXAMINATION 

CVS : S1, S2 + 

RS : BAE + , NVBS 

P/A : SOFT , NON TENDER 

CNS : 

PATIENT IS CONSCIOUS , 

SPEECH : SLURRED 

SENSORY SYSTEM : INTACT 

FACIAL DEVIATION TOWARDS LEFT SIDE.

MOTOR SYSTEM :  

                               R                         L 

TONE      UL   Hypotonic   Normal/hypotonic

                  LL      Hypotonic       Hypotonic 

       

POWER     UL       1/5                  3/5 

                   LL       1/5                  3/5

  

REFLEXES

 

         B      T      S      K        A         P


R      1+     1+     -       -          -         Extensor


L       1+    1+   1+     -          -         Extensor


PROVISNAL DIAGNOSIS 

Seizures secondary to hemorrhagic infarct - left parietal lobe .

? CSVT 

RIGHT HEMIPARESIS WITH BROCA'S APHASIA














INVESTIGATIONS 


30/10/21

Serology - Negative 

























4/11/21

PT -16 SEC.

INR- 1.1

APTT- 32 SEC



TREATMENT GIVEN 

- HEAD END ELEVATION

-IVF - NS , RL @ 75 ML / HR

- INJ. LEVIPIL 500MG IV BD IN 100ML NS

- INJ . MANNITOL 100ML IV TID

- INJ. LORAZ 2CC IV SOS 

- TAB. DOLO 650 MG PO SOS 

- TAB. PAN 40 MG PO OD

- SYP. AMBROXOL 10ML TID

- OINT. THROBOPHOBE FOR L/A

- INJ. CLEXANE 60MG SC OD 



SOAP NOTES

Day2 

ICU BED 4

38 yr old female


S : NO FREASH COMPLAINTS 


O :

SYSTEMIC EXAMINATION 

CVS : S1, S2 + 

RS : BAE + , NVBS 

P/A : SOFT , NON TENDER 

CNS : 

PATIENT IS CONSCIOUS 

SPEECH : SLURRED 

SENSORY SYSTEM : INTACT 

FACIAL DEVIATION TOWARDS LEFT SIDE.

MOTOR SYSTEM :  

                               R                         L 


TONE      UL   Hypotonic   Normal/hypotonic


                  LL      Hypotonic       Hypotonic       


POWER     UL       1/5                  3/5 


                   LL       1/5                  3/5

REFLEXES

         B      T      S      K        A         P

R      1+     1+     -       -          -         Extensor

L       1+    1+   1+     -          -         Extensor


A : 

Seizures secondary to hemorrhagic infarct - left parietal lobe .

? CSVT 

RIGHT HEMIPARESIS WITH BROCA'S APHASIA


P: 

HEAD END ELEVATION

-IVF - NS , RL @ 75 ML / HR

- INJ. LEVIPIL 500MG IV BD IN 100ML NS

- INJ . MANNITOL 100ML IV TID

- INJ. LORAZ 2CC IV SOS 

- TAB. DOLO 650 MG PO SOS 

- TAB. PAN 40 MG PO OD

- SYP. AMBROXOL 10ML TID

- OINT. THROBOPHOBE FOR L/A

- INJ. CLEXANE 60MG SC OD



SOAP NOTES

Day 3

 ICU BED 4

38 yr old female


S : COMPLAINTS OF PAIN AND SWELLING OF RIGHT UPPER LIMB


O :

SYSTEMIC EXAMINATION 

CVS : S1, S2 + 

RS : BAE + , NVBS 

P/A : SOFT , NON TENDER 

CNS : 

PATIENT IS CONSCIOUS 

SPEECH : MONOSYLLABLES +

SENSORY SYSTEM : INTACT 

FACIAL DEVIATION TOWARDS LEFT SIDE.

MOTOR SYSTEM :  

                               R                         L 


TONE      UL   Hypotonic   Normal/hypotonic


                  LL      Hypotonic       Hypotonic       


POWER     UL       1/5                  3/5 


                   LL       1/5                  3/5

REFLEXES

         B      T      S      K        A         P

R      1+     1+     -       -          -         Extensor

L       1+    1+   1+     -          -         Extensor


A : 

Seizures secondary to hemorrhagic infarct - left parietal lobe .

? CSVT 

RIGHT HEMIPARESIS WITH BROCA'S APHASIA


P: 

HEAD END ELEVATION

-IVF - NS , RL @ 75 ML / HR

- TAB. LEVIPIL 500MG IV BD IN 100ML NS

- INJ . MANNITOL 100ML IV TID

- INJ. LORAZ 2CC IV SOS 

- TAB. DOLO 650 MG PO SOS 

- TAB. PAN 40 MG PO OD

- SYP. AMBROXOL 10ML TID

- OINT. THROBOPHOBE FOR L/A

- INJ. CLEXANE 60MG SC OD


SOAP NOTES 

Day 4

AMC BED 3

38 yr old female


S : NO FREASH COMPLAINTS 


O :

SYSTEMIC EXAMINATION 

CVS : S1, S2 + 

RS : BAE + , NVBS 

P/A : SOFT , NON TENDER 

CNS : 

PATIENT IS CONSCIOUS 

SPEECH : SLURRED 

SENSORY SYSTEM : INTACT 

FACIAL DEVIATION TOWARDS LEFT SIDE.

MOTOR SYSTEM :  

                               R                         L 


TONE      UL   Hypotonic   Normal/hypotonic


                  LL      Hypotonic       Hypotonic       


POWER     UL       1/5                  3/5 


                   LL       1/5                  3/5

REFLEXES

         B      T      S      K        A         P

R      1+     1+     -       -          -         Extensor

L       1+    1+   1+     -          -         Extensor


A : 

Seizures secondary to hemorrhagic infarct - left parietal lobe .

? CSVT 

RIGHT HEMIPARESIS WITH BROCA'S APHASIA


P: 

HEAD END ELEVATION

-IVF - NS , RL @ 75 ML / HR

- TAB. LEVIPIL 500MG IV BD IN 100ML NS

- INJ . MANNITOL 100ML IV TID

- INJ. LORAZ 2CC IV SOS 

- TAB. DOLO 650 MG PO SOS 

- TAB. PAN 40 MG PO OD

- SYP. AMBROXOL 10ML TID

- OINT. THROBOPHOBE FOR L/A

- INJ. CLEXANE 60MG SC OD



SOAP NOTES

Day 5

AMC BED 3

38 yr old female


S : NO FREASH COMPLAINTS 


O :

SYSTEMIC EXAMINATION 

CVS : S1, S2 + 

RS : BAE + , NVBS 

P/A : SOFT , NON TENDER 

CNS : 

PATIENT IS CONSCIOUS 

SPEECH : SLURRED 

SENSORY SYSTEM : INTACT 

FACIAL DEVIATION TOWARDS LEFT SIDE.

MOTOR SYSTEM :  

                               R                         L 


TONE      UL   Hypotonic   Normal/hypotonic


                  LL      Hypotonic       Hypotonic       


POWER     UL       1/5                  3/5 


                   LL       1/5                  3/5

REFLEXES

         B      T      S      K        A         P

R      1+     1+     -       -          -         Extensor

L       1+    1+   1+     -          -         Extensor


A : 

Seizures secondary to hemorrhagic infarct - left parietal lobe .

? CSVT 

RIGHT HEMIPARESIS WITH BROCA'S APHASIA


P: 

HEAD END ELEVATION

-IVF - NS , RL @ 75 ML / HR

- TAB. LEVIPIL 500MG IV BD IN 100ML NS

- INJ . MANNITOL 100ML IV TID

- INJ. LORAZ 2CC IV SOS 

- TAB. DOLO 650 MG PO SOS 

- TAB. PAN 40 MG PO OD

- SYP. AMBROXOL 10ML TID

- OINT. THROBOPHOBE FOR L/A

- INJ. CLEXANE 60MG SC OD


SOAP NOTES 

Ward patient

38 yr old female


S : NO FREASH COMPLAINTS 


O :

SYSTEMIC EXAMINATION 

CVS : S1, S2 + 

RS : BAE + , NVBS 

P/A : SOFT , NON TENDER 

CNS : 

PATIENT IS CONSCIOUS 

SPEECH : SLURRED 

SENSORY SYSTEM : INTACT 

FACIAL DEVIATION TOWARDS LEFT SIDE.

MOTOR SYSTEM :  

                               R                         L 


TONE      UL   Hypotonic   Normal/hypotonic


                  LL      Hypotonic       Hypotonic       


POWER     UL       0/5                  3/5 


                   LL       0/5                  3/5

REFLEXES

         B      T      S      K        A         P

R      1+     1+     -       -          -         Extensor

L       1+    1+   1+     -          -         Extensor


A : 

Seizures secondary to hemorrhagic infarct - left parietal lobe .

? CSVT 

RIGHT HEMIPARESIS WITH BROCA'S APHASIA


P: 

HEAD END ELEVATION

-IVF - NS , RL @ 75 ML / HR

- TAB. LEVIPIL 500MG IV BD IN 100ML NS

- INJ. LORAZ 2CC IV SOS 

- TAB. DOLO 650 MG PO SOS 

- TAB. PAN 40 MG PO OD

- SYP. AMBROXOL 10ML TID

- OINT. THROBOPHOBE FOR L/A

- INJ. CLEXANE 60MG SC OD

- TAB. ACITRAM 2MG PO OD 










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