CASE STUDY


By kundana kanumilli (3rd sem)

A 40 year old male came to casualty

CHIEF COMPLIANT

seizure activity

HISTORY OF PRESENT ILLNESS

The patient was apparently asymptomatic 5-6 months back when he had 5 episodes of seizure -Focal [right sided] with secondary generalization which is associated with involuntary micturition for which he was taken to a local hospital and got treated symptomatically

The patient was referred to one hospital for further treatment 
Patient was brought to casualty in a state of altered sensorium
GCS :E3 V4 M5
Patient has history of generalized weakness and body pains since 1 day
there are no other complaints
 
PAST HISTORY

No history of Diabetes mellitus
                        Hypertension
                        Coronary artery disease
                        Asthma
                        Tuberculosis
PERSONAL HISTORY

Married

Normal appetite

Regular bowels

Daily wage labourer

Habits: Alcohol from past 20 years 180ml/day
            
         Smoking Cigeratte from past 20 years 15/ per day 

FAMILY HISTORY

There is no specific family history

GENERAL EXAMINATION

Patient is drowsy,incoherent,co-operative and moderately built examined in well lightened room

NO Pallor 

NO Icterus

NO Cyanosis

NO Koilonychia

NO Lymphadenopathy

NO Edema

Temperature:100F

Pulse rate :96 /min

Spo2 at room air 99%

SYSTEMIC EXAMINATION

CVS

S1 and S2 heard there are no murmurs

RESPIRATORY SYSTEM

Normal vesicular breath sounds,
No wheeze , No dyspnea ,
 trachea is central

ABDOMEN

Shape of abdomen - Scaphoid

No tenderness 

No palpable mass, fluid , bruit

No palpable liver  , spleen

 P/R : no

CNS

Is Drowsy

Incoherent

Glasgow scale E3V4M5





REFLEXES


Right arm :slight increase in intensity

Left arm :slight increase in intensity

Both right and left knee : exaggerated reflex

Plantar reflex: unelicitable

INVESTIGATIONS

COMPLETE URINE  EXAMINATION


HEMOGRAM



Hemoglobin- 12.9 gm/dl
Total count -19000 cells/gm
Lymphocytes -13 % 
PCV -38.1vol %
RBC count -4.42 millions/cumm

ELECTROCARDIGRAM

TREATMENT

Iv Fluids-NS at 100ml/hr[continuos infusion]
Inj CEFTRIAXONE 1 gm IV
Inj LEVIPIL 500mg IV
Inj LORAZ 2cc IV

Inj THIAMINE 1 amp 100 ml NS  IV
Inj OPTINEURON 1 amp 100 ml NS IV
Tab DOLO 650 mg

PROVISIONAL DIAGNOSIS

FOCAL SEIZURE WITH SECONDARY GENERALIZATION 
ALTERED SENSORIUM UNDER EVALUATION
? Meningo encephalitis
?Septic encephalopathy

PLAN

CSF analysis

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