CASE OF 50 YEAR OLD MALE FROM BENGAL WITH BLACKOUTS
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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.
AFEEFA FARZANA ,7th SEMESTER
Roll no:09
CHIEF COMPLAINTS
A 50 yr old male from Bengal presented to the causality with complaints of -
Sudden fall followed by loss of consciousness (black outs) for about 10-15 minutes and sometimes there is involuntary movements of both upper limb and lower limb during the blackout.
The loss of consciousness after waking is usually associated with right unilateral head pain after waking up. He also has no recollection of the incidents on waking.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 32 years back when he had loss of consciousness while lying on the bed at night and not associated with involuntary movements .
Since then he had several episodes of LOC sometimes associated with involuntary movements approximately 2-3 or more attacks per month (diagnosed as epilepsy by the doctors). Almost always associated U/L head ache.
He at times has hard falls which lead to fall of teeth(3 upper incisors and a canine) once, lacerations, contusions on the body.
Involuntary movements - sometimes a/w frothing, not a/w tongue bite, involuntary micturition, involuntary defecation.
They consulted a few doctors but they found no improvement.
A year back they consulted a neurophysician, he gave PHENYTOIN SODIUM 100mg which helped reduce the frequency of the LOC episodes and the U/L head ache , that he usually has after waking up from the episode has also reduced.
A MONTH back without him knowing he removed his clothes and ran for a bit when his wife and brother saw him and got him back home. After this episode when consulted the same doctor, increased the dose to 300mg.
After that episode, he has difficulty in raising both upper limbs above the shoulder and has action tremors.
Life events-
BIRTH- milestones achieved all normal.
18years of age- First episode of LOC.
18yrs- NOW- several episodes of LOC(2-4 per month) and postictal weakness after the episodes and right U/L headache after the episode.
ONE YEAR BACK- Doctor prescribed PHENYTOIN SODIUM 100mg(OD)- reduced frequency and symptoms of blackouts.
ONE MONTH BACK- The unconscious clothes removal episode after which the dose increased to 300mg(OD)
PAST HISTORY
Not a known case of HTN,DM,ASTHMA,TB
Known case of EPILEPSY
PERSONAL HISTORY
Diet: mixed
No relevant family history
GENERAL EXAMINATION
patient was conscious,coherent ,coperative
moderately build and moderately nourished
Pallor: Absent
Icterus: Absent
Clubbing; Absent
Cyanosis; Absent
Lymphedenopathy: Absent
Edema; Absent
VITALS
BP-110/70 mmHg
PR-83 bpm
RR- 17 cpm
SPO2-98% on RA
SYSTEMIC EXAMINATION
CVS- S1 and S2 heard
Respiratory System - NVBS +
Per Abdomen- soft, non tender
CNS-
Speech - normal
No cerebral signs
No meningeal signs
Tone- 5/5 both UL AND LL
Power- 4/5 both UL
5/5 both LL
Sensory system- normal
Cranial nerves - normal
GCS- 15/15
HURT DURING FALLS
ECG
.
DIAGNOSIS-
PERIARTHRITIS OF SHOULDER WITH K/c/o EPILEPSY
TREATMENT-
T. PHENYTOIN SODIUM 100mg PO/OD
T. ZINCOVIT PO/OD
T. FLUPIRTIN P PO/OD
T.PAN 40mg PO/OD
PHYSIOTHERAPY OF SHOULDER
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