18 y/o male with seizures

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CASE:

18Y male came with complaints of involuntary movements of both upper and lower limbs

CHIEF COMPLAINTS:

involuntary movements of both upper and lower limbs 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 day ago , then he developed involuntary movements ,in both upper and lower limbs, which was sudden in onset , associated with shivering,and fever.

He complained of nausea and pain after dinner in the epigastrium which was radiating towards right Iliac fossa and was pricking type with no aggregating factors and relieved on taking medication

There was also history of Shortness of breath 1 hr after playing.

At 11.30 pm he was studying, then was feeling uneasy after which he developed involuntary movements of both limbs.

no history of post-ictal confusion,uprolling of eyeball,tongue bite, involuntary defecation and micturation.

PAST HISTORY:

•No history of HYPERTENSION,DIABETES MELLITUS ,ASTHMA, EPILEPSY, TUBERCULOSIS.

PERSONAL HISTORY:

•DIET:MIXED

•APPETITE:NORMAL

•SLEEP: ADEQUATE (8hrs of sleep)

•BOWEL AND BLADDER MOVEMENTS:REGULAR

•ADDICTIONS:NO

•ALLERGY:NO

FAMILY HISTORY:

•Not significant 

GENERAL EXAMINATION:

•Patient was conscious,coherent and cooperative,well oriented to time place and person,moderately built and moderately nourished.

•Pallor:- absent

•Icterus:- absent

•Cyanosis:- absent

•Clubbing:- absent

•Lymph nodes:- absent

•Edema:- absent

VITAL SIGNS:

•TEMPERATURE: Afebrile

•BP:140/80 mm Hg

•RR: 22/min

•Spo2:99

•GRBS:130 mg%

SYSTEMIC EXAMINATION:

CVS:S1,S2 heard,no murmurs

RESPIRATORY SYSTEM:

trachea central in position

Normal vesicular breath sounds heard

BAE ++

CNS EXAMINATION:

The patient is well oriented to time, place,person.

CRANIAL NERVES EXAMINATION:

All the cranial nerves are intact and functioning.

MOTOR EXAMINATION: 

Power

Rt UL-5/5.            Lt UL-5/5 

Rt LL-5/5.             Lt LL-5/5 

Tone-

Rt UL -N

Lt UL-N

Rt LL-N

Lt LL-N

Reflexes:.       RIGHT           LEFT

Biceps.              ++                   ++

Triceps             ++                   ++

Supinator.       ++                   ++

Knee.                ++                  ++

Ankle.               ++                 ++

Plantar:.       Flexion         Flexion       

•SENSORY EXAMINATION 

crude touch      N                  N

              Pain      N                  N

Temperature     N                 N

     Fine touch     N                N

       Vibration        Right                   Left

     Upper limb.     15 sec                15 sec

     Lower limb.     11 sec.               10sec

                Tibia.      14 sec.               14sec

                   Toe.       15sec.             15sec

Finger nose co-ordination : +

ABDOMEN EXAMINATION:

Inspection :- no scars

Palpation :- soft,non tender

Auscultation :- BOWEL SOUNDS 

INVESTIGATIONS:

HEAMOGRAM:

COMPLETE URINE EXAMINATION:

SERUM ELECTROLYTES:

BLOOD UREA:

Patient's Value:- 23 mg/dl

Normal value:- 12-42 mg/dl

SERUM MAGNESIUM:

Patient's Value:2.0 mg/dl

Normal value:- 1.8-2.9 mg/dl

SERUM URIC ACID:

Patient's Value:- 4.7 mg%

Normal value:- 3.5-7.2 mg%

BLOOD GROUPING AND RH TYPING:

O+ve blood group

SERUM CREATININE:

Patient's Value: 1.1 mg/dl

Normal value:- 0.9-1.3 mg/dl

PROVISIONAL DIAGNOSIS:

SEIZURES

MANAGEMENT:

symptomatic management is administered