case report of a 22 Year old primigravida with known case of epilepsy.

M.VARUN SAI

Roll no. 73 

2017 ( 9th semester)

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CASE REPORT ::

A 22 year old primigravida with gestational age of 10 weeks who is housewife who is a resident of munugodu was brought with 

CHIEF COMPLAINTS :

Muscle spasms involving both upper ,  lower limb and neck since yesterday evening. 

PAST HISTORY ::

Not a known case of DM, HTN, Tuberculosis , asthma.

No history of blood transfusion and major surgeries.

PERSONAL HISTORY :

Appetite :normal

Diet : mixed 

Sleep : adequate 

Bowel and bladder : regular 

No addictions.

No known drug and food allergies.

FAMILY HISTORY :

No history of epilepsy in the family.

GENERAL EXAMINATION :

Patient is conscious coherent cooperative and well oriented to time place and person.

Consent of the patient and attenders was taken and examined in a well lighted room.

Patient is moderately built and nourished.

 Pallor - Present 

Icterus - absent 

Cyanosis - absent 

Clubbing - absent

Lymphadenopathy - absent

Edema - absent

VITALS :

Temperature : afebrile 

Pulse rate - 78 beats per minute , normal rhythm and character and normal vessel wall , no radio- radial and radio femoral delay.

Respiratory rate - 18 cycles per minute 

B.p - 110 / 70 mm of Hg in right arm.

SYSTEMIC EXAMINATION :

CNS 

E4V5M6

Higher mental functions are normal.

Cranial nerve examination is normal.

Motor system : no abnormality detected.

Sensory system : no abnormality detected.

Cerebellum : no abnormality detected.

Pupil :  bilaterally reactive .

CVS :

S1 , S2 Heard , no murmurs

 

RESP. SYSTEM :

Bilateral air entry present.

No vesicular breath sounds  .

P/A :

Soft and non tender .

No organomegaly.

Bowel sounds heard .

Gravid uterus not palpable.

CLINICAL DIAGNOSIS :

 Known case of Generalised tonic clonic seizures.

? Tetany

INVESTIGATIONS :.( Done outside on 4 days back ).

 

 

Investigations ( on 31/03/22)

                              ECG 

               EARLY OBS SCAN 

             2D ECHO 

PROVISIONAL DIAGNOSIS :

EPILEPSY ( GTCS )

? TETANY 2⁰ TO HYPOCALCEMIA

TREATMENT :  ( on 01/04 /22)

INJ LEVIPIL 500mg IV BD

INJ OPTINEURON 1amp in 100ml NS IV OD 

INJ PAN 40mg IV OD 

(Plan for EEG, 2D ECHO, 

USG obs scan with full bladder.)