40 year old male came with the c/o vomitings since 15 days and Shortness of breath since 10 days .He has h/o congenital seizure and restricted to being at home from childhood with fear of being seizure episode anytime .His brother informs he had episode of seizure soon after his birth later on ocassional episodes once every year or two .As brothers used to stay until age 20 and seperated after marrige . Patient wife informs the later on history . The patient inspite of being on medication did have episodes every 2-3 months .Patient had 3 episodes of seizures in this week his wife explains the episode as involuntary movement of upper and lower limbs with drooling of saliva, micturition ,each episode lasting for 1-2 min and had post ictal confusion for 15 - 30 min post seizure activity .
Since the last two week patient c/o vomitings 2-3 episodes per day,non projectile contents being food particles .
No H/o headache ,body pains , burning micturition .
Patient also had history of fever 10 days ago which lasted for 2 days and is insidious in onset ,low grade , subsided on taking medication . Later the patient developed sob which is insidious in onset gradually progressive ( grade 2 to grade 3 ) with no any aggrevating and relieving factors and no diurinal variation .
PAST HISTORY
Not a k/c/o DM, HTN,Asthma , TB.
Patient is on medications for his seizure episodes since child hood ( carbamazepine 300mg OD and Phenytoin 100mg TID)
TREATMENT HISTORY
The patient recollects he was using only carbamazepine 300mg twice daily uptill February this year when he visited a physician at local hospital where in he was adviced levipil 250mg BD for a month but wasn’t compliant to both medications.
In the month of march he was started on phenytoin 100 mg TID
No significant family history .
Drinks alcohol ocassionally.
GENERAL EXAMINATION
Pt is c/c/c
No pallor , icterus , cyanosis, lymphadenopathy, edema.
VITALS
TEMP : 98.4F
PR: 100BPM
BP 100/80 MMHG
RR : 22 CPM
SPO2 : 97 ON RA
SYSTEMIC EXAMINATION
CVS : S1,S2 +
RS : BAE +
P/A : SOFT ,NON TENDER
CNS:
Pt is c/c/c with well orientation to time, place and person.
HMF - intact.
Cranial nerves: intact.
Motor system :
UL LL
- Power : R. 5/5. 5/5
L. 5/5. 5/5.
- Tone : R. N N
L. N N
- Reflexes : B T S K A P
R 2+ 2+ 2+ 2+ 1+ Extensor
L 2+ 2+ 2+ 2+ 1+ Flexor
Sensory system : Intact
PROVISONAL DX
Recurrent seizures under evaluation
Gastritis
INVESTIGATIONS
17/10/21
Serology - Negative
18/10/21
19/10/21 - USG ABDOMEN
RX GIVEN
1. INJ . LEVIPIL 1GM IV STAT
INJ.LEVIPIL 500MG IV BD
2. INJ. LORAZEPAM 2CC IV SOS
3. INJ OPTINEURON 1 AMP IN 100ML NS IV OD
4. INJ. ZOFER 4MG IV SOS
5. INJ . PAN 40 MG IV OD
6. MONITER VITALS
7. GRBS MONITERING 4TH HOURLY.
AMC BED 7
SOAP NOTES Day 2
18/10/21
AMC patient
A 45 year old male patient with C/O H/o epilepsy since childhood. Vomitings since 2 weeks.
S: c/o pain and burning sensation at corners of mouth.
O: Patient is conscious, coherent and cooperative.
No pallor, icterus, cyanosis, lymphadenopathy, pedel edema
BP : 110/70 mmhg
PR: 66 bpm
Temp: afebrile to touch.
SpO2: 99 on RA
RR: 16 cpm
CVS: S1 AND S2 heard.
RS: BAE +, NVBS.
P/A: soft and no-tender.
CNS:
Pt is c/c/c with well orientation to time, place and person.
HMF - intact.
Cranial nerves: intact.
Motor system :
UL LL
- Power : R. 4/5. 4/5
L. 4/5. 4/5.
- Tone : R. n. n
L. n. n
- Reflexes : B T S K A P
R 2+ 2+ 2+ 2+ 1+ Extensor
L 2+ 2+ 2+ 2+ 1+ Flexor
A: - RECURRENT SEIZURES ( NON COMPLAINT TO MEDICATION ).
Plan for treatment:
IVF - 1unit Ns , 1 unit RL
INJ. PAN 40 mg iv OD
INJ ZOFER 4 MG IV OD
INJ OPTINEURON in 500ml ns OD
TAB. EPTOIN 100 MG TID
TAB. CARBAMAZEPINE 300 MG BD
ZYTEE GEL FOR L/A
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