General medicine

K.Rohit
3rd semester,


This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs.





#This  is an ongoing case , and will be updated as and when the information is provided.

This e-log has been made under the guidance of Dr.Harika.

Date of admission-7/8/21

Case in brief-
A 35 old female came to the casuality with cheif complaints of single episode of seizure attack since 2 hours

Cheif complaints -
• Seizure attack since 2days
• fever (4 days)- low grade intermediate,relived with medication,not associated with chills and rigors.
•Involuntary movents of right upoer limb  and lower limb

HISTORY OF PRESENT ILLNESS:
•Today morning patient had weakness of right upper limb and lower limb, went to local hospital and took treatment.
•After 1hour while doing her bank work suddenly she had stifness of right upper limb and stiffness of neck right side.
•Later she developed involuntary movement of right upper limb and lower limb.
•No involuntary micturition and defecation
•No up rolling of eye ball
•Every episode lost for 5 minutes
•On presentation to casuality she had 1 episode of involuntary movement of right upper limb and lower limb.

TREATMENT HISTORY-
not significant.

PERSONAL HISTORY:
Diet - non vegeterian
Apetite - decreased
regular bowels
normal micturition
no known ellergies
no addictions.


not significant.

Vitals :
BP-120/80 mmhg
RR-18 cpm
spo2- 99% at room temperature
GRBS-119 mg/dl

GENERAL EXAMINATION:
Consious and coherent
Pallor positive
no signs of icterus,
No signs cynosis
Noclubbing
No lymphadenopathyk
No oedema of feet.

SYSTEMIC EXAMINATION:
Respiratory examination

DAE(+)

CVS EXAMINATION
- s1 and s2 are heard
PA-Soft and non tender

CNS-

No abnormality detected

EYE examination

          O/E                           RE                     LE   
• Lids                         Normal            Normal
• Conjuctiva              quiet                  quiet
• Cornea                      clear                  clear
• Anterior chamber   NAD                 NAD
• Pupil                drug mydriatic          drug
•                                                              Mydriatic
• Lens                        clear                   clear


Fundus examination
                                      RE                               LE
• Optic disc     normal size ,well     Normal
•                        Defined margin               size
• CDR                   0.3:1                          0.3:1
• VESSELS           normal                    normal
• MACULA           FR dull                       FR dull

Impression- No raised ICT changes noted .

Investigations
MRI Brain

Anti HCV Antibodies

HIV Rapid Test

HbsAg -Rapid

Provisional diagnosis
Focal seizures

Treatment

7/8/21
• Inj optineuron 1amp in 100 ml NS-IV ,OD
• Tab PCM 650 mg oral , TID
• Tepid sponging
• Temperature motoring 4th hourly
• Inj levipil 500 mg IV-BD
• Inj lorazepam IV SOS

8/8/21
• Inj optineuron 1amp in 100 ml NS-IV ,OD
• Tab PCM 650 mg oral , TID
• Tepid sponging
• Temperature motoring 4th hourly
• Inj levipil 500 mg IV-BD
• Inj lorazepam IV -SOS

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