20M Recurrent 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, and investigations, and come up with a diagnosis and treatment plan.

20 year old male with involuntary upper and lower limb(seizures)

CHIEF COMPLAINTS:

4 to 5 episodes of involuntary movements of upper and lower limbs (seizures)from 4 am in the morning (19/07/23) 2 to 3 minutes with up rolling of eyes and froathing mouth .post ictal confusion present for 10 minutes

HISTORY OF PRESENT ILLNESS:

Patient was apparently normal till 7 years of age, he then had an episode of involuntary movements of upper and lower limbs with up rolling of eye lids and froth from mouth. Each episode lasts for 1-2 minutes. 

He was then taken to a hospital where he was diagnosed as a case of epilepsy and put on treatment. Post ictal confusion +ve.

Patient was having seizure episode in every 1-2 months and relieved by themselves.

According to parents, the intensity of each attack is increasing from past one year. 

Last seizure episode was 6-7 months back.

No h/o vomitings, involuntary passage of urine or stools.

Aggravating factors : fever during rainy season and shivers during contact wi

th cold water.

HISTORY 

Patient has h/o delayed milestones.

Patient is k/c/o epilepsy since the age of 7 years (13 years) and medication given was Tab. Sodium valproate 500mg PO/OD, Tab. Oxcarbazepine 450mg BD, Tab. Phenytoin 100mg OD. 

Not a k/c/o DM, TB, HTN, asthma, CAD.

DETAILS OF SEIZURES ACTIVITY:

9 months pregnancy - no movements present didn't have labour pain

LSCS done didn't cry ? seizures @8th day in NICU (doctor explianed that baby will will have delayed milestones)

AGE OF 6 MONTHS :

Fever with seizure advised to use antiepileptic for 3 yrs but used only for 6months.

Age 7 yrs:

H/O Fall from bed associated with absent seizure which continued for next 6 months till 9yrs of age.

Age 9yrs:

2-3 seizures every 1 month

Age 10yrs:

Absent seizures later followed by generalised seizures

Age 13 to 19 yrs

Seizure activity for every 1 month 

Bending knees while walking 

Age 19.5

Admission in kims for seizure activity

Age 20yrs

A gap of 6months present from previous activity

MILESTONE EVENTS DELAYED :

GROSS MOTOR 

3 months :lifts head by 5 months

6 months: tripod postion by 8-9 Monty

12 months:14-15 months standing and walking

walking without support @3yrs

3 years:3and half years he started running

5years:5 and 1/2 he started walking up the stairs 

FINE MOTOR

3 months: gripping and grasping @ 6 months

2-3 yrs stacking blocks delayed by 2-3 months 

SOCIAL AND ADAPTIVE MILESTONES

6 months: couldn't get scared by strangers

9 months: @1 yr couldn't say bye bye

1year: couldn't play

18 months: copies parents tasks

2years :ask for food drinks

3 yrs: could tell his full name and gender

5yrs: could help in household tasks but couldn't dress and undress

SPEECH DELAYED:

key language milestones all on time except mono and bisyllable words delayed 

FAMILY HISTORY:

Significant family history present 

Oblique transmission:From uncle 

His uncle has

 history of seizures 10 years ago

DAILY ROUTINE:

He wakes up at 6 o clock and does his daily activities then he sees TV and cell phone and does small work at home .At 12 o clock he eats lunch if the curry is tasty and sometimes he skips his lunch .At 9 o clock he eats dinner and then he’ll sleep .

EXAMINATION 

Patient is conscious and oriented

PR:68 bpm

BP:120/80 mmHg

RR:18 cpm

RS:BAE+ no added sounds

CVS: s1 and s2 heard no added sounds

Per abdomen:soft and non tener

Pupils:NSRL

GCS:15/15

                  UL. LL

Tone R. N. N

           L. N. N

Power R. 5/5. 5/5

            L 5/5. 5/5

CRANIAL NERVE EXAMINATION 

                                                     Rt lft

I - sense of smell + + 

II - visual acuity 20/20 20/20

      color vision + + 

III extraocular movements normal

IV - light reflex + +

VI accommodation reflex + +

       Ptosis - -

       Nystagmus - - 

V sensory normal

    Motor normal

   Reflex

Corneal reflex + +

Conjunctival + +

Jaw jerk + + 

VII Motor normal

       Sensory normal

        Reflex corneal + +

                         Conjunctival + + 

VIII Rinnies positive positive

Weber not lateralised 

IX,X uvula lateralised to the left 

         gag reflex Absent

          Palatal reflex absent 

XI Trapezius and SCM good

XII Tone mild hypertonia 

          Wasting no

          Tongue protrusion deviate to left

INVESTIGATIONS

CHEST X ray ap view