General medicine case 10

General Medicine Case 10

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A 21 year old female who is studying Degree came to OPD with Chief complaints of seizures since 1 month.

History of Present illness:-

Patient was apparently asymptomatic since 2 years. She diagnosed as Diabetic and Hypothyroid 2 years ago as she had fever which lasted for 15 days . Fever - high grade associated with chills and rigors went to hospital.She came to OPD with Chief complaints about seizure since 1 month. It is GCTS type of seizures lasted for 10 minutes  , 1 episode - no tongue bite ,froth from mouth , involuntary defecation , micturition ,uprolling of eye.

She had these seizures everytime at night around 1 to 3 am since 1 month. Till now she had 4-5 episodes since 1 month.

Routine:- She used to wake up between 6-7 A.M

Have her breakfast at 8 A.M. She goes to clg by 9A.M. Have her lunch by 1 P.M. And returns home from college by 5 P.M and does household work. By 8 P.M have her dinner. And by 10-11 P.M she goes to sleep.

Past History:-

She has Diabetes and Hypothyroid since 2 years.

No history of Asthma, Hypertension, epilepsy, Tuberculosis.

Personal History:- 

Patient has mixed diet.

Sleep - adequate.

Appetite - normal.

Bowel and bladder movements normal.

Menstrual period is normal.

Family History:- 

No members in family has similar complaints.

Treatment History:-

Patient was on insulin since 2 years ,earlier doses of 30 u -x- 50 u , increased dose of insulin mixtard since 20 days .

Patient was on thyronorm 75 mcg ,stopped since 4 months .

General examination:-

Patient is conscious, coherent, well oriented to place and time.

Patient was Moderately nourished.

No anemia, no pallor, no icterus ,no cyanosis , no clubbing.

No generalised lymphadenopathy.

Vitals:- 

Temperature - afebrile 

Blood pressure - 110/70 mmHg 

Pulse rate - 74 bpm

Respiratory rate - 17 cpm

Systemic Examination:-

CVS - S1 S2 + 

RS - bae + 

CNS - no focal neurological deficits 

Per Abdomen- soft , non tender , no organomegaly , bowel sounds+.

Investigations:-

HB - 10.5 g/dl

TLC - 16,200 

PLt - 5.15 

Rbs - 230 mg/dl

Blood urea - 13 mg/dl

Cue : trace albumin , nil sugars ,pus cells - 2 to 4 

Serum creatinine - 0.6 mg/dl

Lft : tb - 0.66 , db - 0.20 , ast - 26 iu/l , alt - 14 iu/l , alp - 252 iu/l , tp - 6.4 g/dl, albumin - 3.7 g/dl , a/g ratio - 1.42 

Electrolytes : Na - 144 , K - 4.3 , Cl - 97 

Spot urine protein - 21 

Spot urine creatinine - 47.4 

Ratio - 0.44 

Serum iron - 62 mcg/dl

Ultrasound abdomen - no sonological abnormality detected 

Provisional diagnosis:-

Seizures under evaluation 

? Hypoglycemic seizures 

? Epileptic disorders 

Treatment:- 

1.inj lorazepam 2 cc IV SOS 

2.inj Optinneuron 1 amp in 100 ml ns iv od 

3.inj insulin mixtard s/c bd 30-x-30 units 

4.grbs charting 7 point profile 

5.bp/pr /SPO2/temp charting 4th hourly