A 57y/M with C/O of stiffness of B/L upper and lowerlimb
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A 57year old male came to the opd with complains of stiffness of bilateral upper and lower limbs for 15minutes since 1day
HOPI:
Patient was apparently normal until yesterday morning then he developed stiffness of all four limbs for 15minutes associated with of up rolling of eyes frothing from mouth and involuntary micturition, tongue bite+
No involuntary defication present,
Post ictal confusion is present for 5-10mins, no history of similar complains in the past.
No history of fever, headache, vomitings
N/K/o HTN, DM, CVA, CAD, ASTHMA, TB, EPILEPSY
PAST HISTORY
N/K/C/O DM, TB, epilepsy, CVA, CAD, thyroid disorders and bronchial asthma
FAMILY HISTORY:
Not significant
PERSONAL HISTORY:
Diet :Mixed
Apetite:Normal
Bowel and bladder Movements:Regular
Sleep:Adequate
Addictions occasional alcoholic, regular beedi smoker 10-15/day since 12years.
No allergies
Daily routine: Patient wakes up at 4am and does a few household chores along with his wife untill 7am and relaxes between 7am to 9 am. He goes to his work by 10am and has his lunch at 2 pm, continues work upto 5:30 and returns home at 6pm and has tea and watches television until 7pm. Has dinner by 9:30, sleeps by 10 pm.
All of a sudden prior to his admission in the hospital, patient experienced stiffness of all four limbs and frothing through his mouth for approximately 15mins at 7:00Am in the morning, for which he was taken to a government hospital nearby and was given treatment and was reffered to our hospital.
No change in daily routine due to his seizures.
GENERAL EXAMINATION:
On examination patient is conscious, coherent, cooperative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
VITALS:
Temp-Afebrile
PR-82bpm
RR: 14Cpm
BP:130/80mm Hg
Spo2:99% at room air
GRBS charting: 98mg/dL
Systemic examination:
Per abdomen:
Soft,Nontender
RS:
bilateral air entry is present.
Normal vesicular breath sounds are heard.
CVS:
S1S2 heard.No murmurs
CNS:
HMF+,NFND
Provisional Diagnosis:
SEIZURES UNDER EVALUATION
INVESTIGATIONS
Hemogram:
⁹CUE:
Serum electrolytes:
Serum creatinine:
Blood urea:
Treatment :
Levipil 500mg PO/BD 8AM------8PM
Vital monitoring every 4th hour.
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