26 Y/M WITH HTN AND FOCAL SEIZURES UNDER EVALUATION

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
Here is a case i have seen:
CASE HISTORY:
A 26 YEAR OLD MALE ,PLANT NURSERY WORKER BY OCCUPATION, CAME TO THE HOSPITAL WITH COMPLAINTS OF INVOLUNTARY TWITCHING MOVEMENTS OF LEFT UPPER LIMB YESTERDAY NIGHT.

PT WAS APPARENTLY ASYMPTOMATIC ONE MONTH BACK,THEN ONE DAY WHILE LISTENING SONGS,HE SUDDENLY DEVELOPED TINGLING SENSATION IN LEFT UPPER LIMB ,FOLLOWED BY TWITCHING OF LEFT UPPER LIMB LASTING FOR 1 TO 3 MINUTES ASSOCIATED WITH DEVIATION OF MOUTH TO LEFT AND SLURRING OF SPEECH AND FROTHING ASSOCIATED WITH HEAVINESS OF HEAD AT THE TIME OF EPISODE

NO H/O LOSS OF CONSCIOUSNESS,POST ICTAL CONFUSION,INVOLUNTARYMICTURITION,DEFECATION.UPROLLING OF EYEBALLS,TONGUE BITE. 

THEN HE WAS STARTED ON TAB LEVIPILL 250MG BD

H/O SIMILAR EPISODE LIKE THE FIRST ONE BUT WITHOUT DEVIATION OF MOUTH HAPPENED 3 DAYS AFTER HIS FIRST ADMISSION TO THE HOSPITAL ONE MONTH BACK  WHEN HE CONSUMED TODDY AND SKIPPED DOSE OF TAB LEVIPILL 250MG.HE THEN WENT TO THE HOSPITAL AND DOSE OF TAB LEVIPILL  WAS INCREASED TO 500mg from 250mg.
HE DEVELOPED SIMILAR EPISODE WITH NO LOC,TONGUE BITE,FROTHING,INVOLUNTARY MICTURITION,DEFECATION
THEN AGAIN 15 DAYS LATER , HE SKIPPED THE MORNING DOSE AND HAD THE SIMILAR EPISODE 
PT WAS AWARE OF THE EPISODE

K/C/O HTN SINCE 1 MONTH( BP recorded at tht time was systolic 170mmhg) 
ON TAB:CLINIDIPINE 20 mg/PO/OD [USED FOR 10 DAYS AND STOPPED]

NOT A K/C/O DM,ASTHMA,TB,CVA,THYROID DISORDERS
PERSONAL HISTORY:
HE IS A NON VEGETARIAN,HAS NORMAL APPETITE AND ADEQUATE SLEEP.
KNOWN ALCOHOLIC SINCE 5 YEARS [90ML/DAY] EVERY 3RD DAY--HIS LAST DRINK WAS 1 MONTH BACK.
SMOKES 1 TO 2 CIGARETTES PER WEEK
GENERAL EXAMINATION:
PT IS C/C/C , MODERTAELY BUILT AND NOURISHED

NO SIGNS OF PALLOR, ICTERUS,CYANOSIS,CLUBBING,EDEMA,LYMPHADENOPATHY.

VITALS
TEMP    -AFEBRILE
PULSE  -72bpm
RR         -16cpm
BP         -130/80mmhg
SPO2    -98%
GRBS    -113mg/dl
SYSTEMIC EXAMINATION:
 CVS   -S1S2 HEARD, NO MURMURS

RS      -BAE +,NVBS

P/A    - SOFT ,NON TENDER, NO ORGANOMEGALY

CNS   -PT IS CONSCIOUS, SPEECH IS NORMAL,                 NO SIGNS OF MENINGIAL IRRITATION,        
HIGHER MENTAL FUNCTIONS
Speech is normal
Fluency is normal
Comprehension- present
Repetition          -present
Naming              -intact
Writing               -intact

Motor System Examination 
Tone      Upper Limb             Lower Limb
Right          Normal               Normal 
Left             Normal              Normal 
Bulk       
Arm          Normal bilaterally
Forearm    Right forearm is a little bulkier than left forearm   
Thigh         Normal bilaterally
Leg            Normal bilaterally
Power  
Upper limbs-5/5
lower limbs-5/5
Hand grip 100% in both sides

Superficial Reflexes
                             Right     Left   
Corneal                  +            +
Conjunctival          +            + 
Abdominal             +            + 
Plantar                  mute    mute

Deep Tendon Reflexes 
                                   Right      Left                                      Biceps                 1+           1+
       Triceps                 -              -
       Supinator             -              -
       Knee                     -           1+
      Ankle                      -              -   
 CRANIAL NERVES- INTACT
Cerebellar Examination
Dysdiadokinesia: absent
Finger nose: no incoordination
No Tandem walking
Sensory System Examination
Pain and temperature sensation-intact
Vibration sense-intact
Joint sense       -intact

Gait-normal

INVESTIGATIONS

ELECTROLYTES-
    
RBS- 94mg/dl
HEMOGRAM
THYROID PROFILE

LIPID PROFILE
LFT


USG-NO SONOLOGICAL ABNORMALITY                           DETECTED
ECG - 
2d-ECHO- 
FUNDOSCOPY- NO RAISED ICT CHANGES
    -NO HYPERTENSIVE  RETINOPATHY CHANGES        SEEN

MRI FINDINGS:
-INCIDENTAL TINY HIPPOCAMPAL SULCAL REMNANT CYSTS
-DILATED PERI-OPTIC CSF SPACES AND EMPTY SELLA_ SUGGESTED FUNDOSCOPY TO RULE OUT ICT

DIAGNOSIS
-FOCAL AWARE TONIC CLONIC SEIZURES OF LEFT UPPER LIMB
_YOUNG ONSET HYPERTENSION
TREATMENT
-TAB LEVIPILL 500MG/PO/BD
-TAB PANTOP 40MG/PO/OD
-TAB CINOD 10MG/PO/OD
-INJ OPTINEURON 1 AMP IN 100ML NS/IV/OD







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