Case history -8

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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, investigations and come up with diagnosis and treatment plan

A 22 female came to OPD with c/o seizures since 1 month 

-GTCS type of seizures lasted for 10 minutes , 1 episode - no tongue bite ,froth from mouth , involuntary defecation , micturition ,uprolling of eye + .

-had 4-5 episodes since last 1 month .

-she had these seizures everytime at night around 1 to 3 am since 1 month 

-post ictal confusion + 

-patient was apparently asymptomatic 2 years ago ,had fever which lasted for 15 days . Fever - high grade associated with chills and rigors went to hospital in Hyderabad ,there she was diagnosed as diabetic and hypothyroid 

-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 

-No h/o pedal edema ,sob , facial puffiness , burning micturition ,froathy urine 

Personal history : 

Diet - mixed 

Appetite - normal 

Sleep - adequate 

Bowel and bladder habits - regular 

No addictions 

General examination : 

Patient is c/c/c 

Pallor + mild .No h/o clubbing , cyanosis , lymphadenopathy , icterus , 

Temp - afebrile 

Bp - 110/70 mmHg 

Pr - 74 bpm

RR - 17 cpm

Systemic examination : 

CVS - S1 S2 + 

RS - bae + 

CNS - no focal neurological deficits 

P/a - soft , non tender , no organomegaly , bowel sounds + 

Investigations : 

Hemogram - 

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 

S.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

Chest x-ray pa view 

ECG 

USG abdomen - no sonological abnormality detected 

GRBS charting 7 point profile :

10 pm - 208 mg /dl

2 am - 152 mg/dl 

6am - 111 mg /dl 

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