A 21 YEAR OLD FEMALE WITH C/O HEADACHE AND INVOLUNTARY MOVEMENTS
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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CASE DISCUSSION:
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
HOPI:
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:
- 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
CLINICAL IMAGES:
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
2D ECHO: https://youtu.be/wZAYPcDaEGE
Day 2:
S: No fresh Complaints
O:
Pt conscious,coherent,cooperative, well oriented to time place and person.
Pallor Present
Vitals:
Bp:110/80
Pr:90bpm
Rr:20cpm
Temp:99.2f
Grbs:96mg/dl
Spo2:97%
SYSTEMIC EXAMINATION:
CVS:s1,s2 +
Rs:bae+
P/a: size of uterus:corresponding to 12wks
Article on: causes of postpartum seizures
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