22 year old female 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.
22 year year old female who is a student completed degree few months back resident of narayanapuram mandal
Chief complaints:-
She came to the casualty with the chief complaints of seizures since 1 month.
HOPI :-
Patient was apparently asymptomatic 2 years back
Then she developed high grade fever associated with chills and rigors went to hospital in Hyderabad where she was diagnosed with typhoid , diabetic and hypothyroid.
1 month back she had an episode of seizure lasted for
About 10-15 mins, with uprolling od eyes, no tongue bite and froth from mouth.
In the past 1 month she had 4 similar episodes which occurred at night around 1-3 am.
She didnt remember it after waking up.
Post ictal confusion +
She was on insulin since 2 years , earlier doses were 30U -x- 50U then she went to local doctor there her dose was increased to
50U - x- 70U and according to patients attender seizures were observed when the dose was increased.
She used thyronorm 75 mcg used for 5-6 months and stopped it and started using local Treatment ( natu vaidyam )
- no history of pedal edema , sob ,facial puffines, burning micturition.
Vedio at the time of seizures :-
Personal history-
Diet - mixed
Appetite- normal
Sleep - adequate
Bowel and bladder- regular
Addictions- nil
Past history -
diabetic from 2 years
no similar complaints are seen
Family history:- similar complaints are seen in her uncle
Treatment history:-
Insulin mixtard 30U -x- 50U
Thyronorm 75 mcg
General examination:-
Patient was conscious coherent and co-operative
And well oriented to time place and person
Pallor - mild
No history of icterus, Clubbing, cyanosis, lymphadenopathy
Temperature - 98.6F
BP - 110/80 mm of Hg
PR - 76 bpm
RR - 18 cpm
Systemic examination:-
CVS - S1 S2 +
RS - bae+
CNS - no focal neurological deficits
Per abdomen- soft , non tender, no organomegaly
Investigations:-
Abnormal parameters
Hemogram-
HB - 10.5 g/dl
TLC - 16,200
RBS - 230 mg/dl
CUE - trace albumin
GRBS:-
10 pm - 208 mg/dl
2 am - 152 mg/dl
6 am - 111 mg/dl
HbA1C - 6.8
Thyroid profile :-
ECG :-
Provisional diagnosis :-
Hypoglycemic seizures/
Epileptic disorders
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