general medicine blog

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome


A 30 yr old male who is a student resident of suryapet came to general medicine OPD with chief complaints of involuntary stiffening of left upper and lower limbs sence 18 yrs.

HISTORY OF PRESENTING ILLNESS:
          Patient was apparently asymptomatic 18 yrs back then he started developing involuntary movements and stiffening of left upper and lower limbs associated with up rolling of eyes,froathing, headache,loss of language,fear, anxiety, apnea,stertoreus breathing,vocalization during episode and loss of balance .
Not associated with involuntary micturition, defecation and tongue biting
Episodes:2-3 per month 
History of triggering of seizure activity by stress.history of decreased hearing in the left ear associated with tinnitus .
Drug history:
patient is on tablet.carbamazapine 200mg po/BD but the seizure activity is not subsiding.
PAST HISTORY:
N/k/c/o thyroid disorder,CVA,CAD,Asthma,TB,HTN, Diabetes
FAMILY HISTORY:
No history of seizure disorder in the family
PERSONAL HISTORY:
Diet :mixed
Appetite:normal
Sleep: adequate
Bowel and bladder movements:regular
No addictions
No known allergies

GENERAL EXAMINATION:
Patient is conscious coherent and cooperative well oriented to time and place
No pallor 
No icterus
No cyanosis
No clubbing
No pedal edema
No lymphaadenopathy 

Vitals:
Temperature:afebrile
BP:120/70 mmHg
RR:11cpm
PR:88/min

SYSTEMIC EXAMINATION:
CVS:
S1,S2 present,no thrills ,no murmurs
RESPIRATORY SYSTEM:
position of trachea central 
No history of dyspnea and wheeze
Normal vesicular breath sounds are heard
PER ABDOMEN:
Shape of the abdomen:scaphoid
No tenderness
No palpable masses
No hepatosplenomegaly
CNS:
speech:normal
Gait:normal
No signs of meningitis 
Glasgow scale:G4V5M6
Cerebellar signs -
Finger nose test-coordinated
Knee-heek test-coordinated
Dysdiadokinesia-positive
Nystagmus-absent

PROVISIONAL DIAGNOSIS:
Seizures-GTCS???

INVESTIGATIONS:

HEMOGRAM:
HB-15.6
TLC-5,700
PCV-44.7
PLATELET COUNT:2.1 LAKH

COMPLETE URINE EXAMINATION:
Albumin-trace
Sugar-nil
Bile salts-nil
Bile pigments-nil

RFT:
urea-23
Creatinine-1.0
Uric acid-3.8
Calcium -10.0
Na+ -144
K+ -4.1
Cl- -106

LFT:
Total bilirubin:0.56
Direct bilirubin:0.18
SGOT-21
SGPT-13
ALP-163
TP-7.9
RBS-100mg/dl

ECG:

TREATMENT:
            Tab.carbamazapine-200mg po/tid
             Tab.MVT-po/od
              Watchful for seizure activity

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