MACHYAGIRI

 

C/O INVOUNTARY MOVEMENTS OF ALL FOUR LIMBS SINCE TODAY MORNING.

 

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARETNLY ASYMPTOMATIC UNTIL TIDAY MORNING , THEN AT AROUND 10:30 AM , PATIENT HAD INVOLUNTARY MOVEMENTS OF ALL FOUR LIMBS , TONIC , CLONIC  TYPE LASTER FOR 5 MINUTES, 4 EPISODES , EACH LASTED FOR 2-5 MINUTES. NO LOSS OF CSNSCIOUSNESS IN BETWEEN EPISODES . POST ICTAL CONFUSION PRESENT. H/O UPROLLING OF EYES AND DROOLING OF SALIVA  . NO H/O TONGUE BITE. NO H/O INVLUNTARY PASSAGE OF URINE / STOOLS.

PAST HISTORY:

N/K/C/O DM , CVA, CAD, SEIZURES , ASTHMA

K/C/O HTN SINCE 6-7 MONTHS , NOT ON ANY MEDICATION.

PERSONAL HISTORY:

DIET – MIXED

SLEEP – ADEQUATE

APPETITE – NORMAL

BOWEL AND BLADDER – REGULAR

NO KNOWN ALLERGIES

NO HABITS OR ADDICTIONS

GENERAL PHYSICAL EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT , AND COOPERATIVE

NO PALLOR , ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY , EDEMA

VITALS:

BP – 90/60 MMHG

PR – 120 BPM

RR – 28 CPM

TEMPERATURE –  99.9 F

SPO2 –  82% AT RA

GRBS – 218 MG%

SYSTEMIC EXAMINATION:

CVS- S1S2 HEARD , NO MURMURS

RS –BAE+ , NVB S+  , DECREASED ON LEFT SAA

PER ABDOMEN : SOFT ,NON TENDER , NO ORGANOMEGALY

CNS EXAMINATION:

GCS – E4V5M6

PUPILS – NSRL

MOTOR –

TONE     - RT         LT

UL           -   N         N

LL              -   N      N

POWER

UL -      5/5          5/5

LL  -      5/5          5/5

REFLEXES : RT         LT

BICEPS -    2+            2+

TRICEPS – 2+              2+

SUPINATOR -    -            -

KNEE -      2+       2+

ANKLE -    -           -

PLANTAR -   FLEXION     FLEXION

INVESTIGATIONS:

TROPONIN I – 22.3 PG/ML

 

PROVISIONAL DIAGNOSIS:

FOCAL TO B/L TONIC CLONIC SEIZURES SECONDARY TO YOUNG ONSET STROKE

? NCC

K/C/O HTN

TREATMENT:

INJ.CEFTRIAXONE 1 GM IV/BD

INJ.LEVIPIL 500 MG IV/OD

INJ.PAN 40 MG IV/OD

TAB ECOSPIRIN 150 MG PO/OD

TAB CLOPITAB 75  MG PO/OD

TAB ATORVAS 40 MG PO/HS

TAB TELMA 20 MG PO/OD

INJ DEXA 4 MG IV/STAT

INJ DEXA 4 MG IV/TID