25 year old male with an episode of seizures

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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.

CASE:

25 yr old male resident of devarakonda farmer by occupation came to general medicine OPD with chief complaints of an episode of seizure 25 days back.

HOPI:

Patient was apparently asymptomatic 12 years back then he developed an episode of seizure which is sudden in onset ,it started as dragging type of pain in his right hand ,radiating upto his shoulder ,the pain is so severe that he feels like Someone is twisting and chopping off his hand associated with jerky movements of that hand then he fell unconscious,the whole episode lasted for 3-5 minutes, associated with tongue biting.

Not associated with frothing from mouth, uprolling of eyes , postictal confusion,and autonomic symptoms like urination and passage of stools during seizure episode.

After the first episode he took some ayurvedic medicine for 2-3 months but  he got another similar episode of seizures ,then he went for another ayurvedic medicine and used it for 2 months but he again experienced similar episode,after these 3 episodes he came to kamineni hospital .

In kamineni hospital they diagnosed it as Right complex partial seizures and gave Tegretol  and he continued to use this medication for 3 years with regular follow up of once in three months .He stopped the medication by himself without any advice From his doctor .

After this 12 years of seizure free period he got 4 th episode 25 days back .

On the day of 4th episode he woke up at 7 o clock and ate rice at 9 o clock went to farm to work ..at around 12 o clock he climbed palm tree for toddy extraction but he felt a bad aura that he is going to have seizures as some pain started in his right hand then he immediately came down and sat in a safe place ,then same like first episode he experienced dragging type of pain which is increasing as it radiating to shoulder as if his hand is chopped off from his body ,with jerky movements followed by period of unconscious .There were no one around him at that time of incident ,he regained his consciousness and went home ,after two days went to rmp doctor he gave an injection and tablets ,due to financial problems he didn't visit hospital immediately after seizure episode . 

History of eating pork 6 months back 

History of intake of 3- 4 beers before two days of attack and increased work load ,severe physical exhaustion during this season.

No history of fever , neck stiffness,vomitings,headache.

DAILY ROUTINE:

He daily wakes up at 7'0 am , eats rice at 9'0 am after eating he goes to work in their farm , usually they cultivate paddy and Cotton ,

He eats lunch at 1:00 pm and again work in the field upto 5:30 or 6:00 ,after work he will go to home and fresh up and goes out with his friends and drinks 2-3 beers once in 3 days  then he eat something and goes to bed , usually sleeps around 10 pm.

Past history:-

History of truma to head  when he is 1 month old ,he fell down from the bed .

Not a know case of diabetes mellitus, hypertension,tb, asthama, thyroid disorders.

Personal history:-

Diet :- mixed

Appetite:- normal 

Sleep :- adequate

Bowel and bladder movements:- regular

Addictions :- drinks 2-3 beers once in 3 days .

Family history:- 

 Similar complaints observed in his elder sister when she is 12 years old but didn't recurred after taking ayurvedic medicine.

No other family members have any significant history

GENERAL EXAMINATION:

Patient is conscious,coherent and co-operative.well oriented to time,place and person.

Moderately build and moderatly nourished.

No pallor, icterus, cynosis,clubbing, lymphadenopathy ,edema

Vitals:-

BP:140/90(lft arm)

PULSE RATE:82/min

RESPIRATORY RATE:20cycles/min

TEMPARATURE:afebrile

* CNS EXAMINATION:

Right handed person 

HIGHER MENTAL FUNCTION

Counsious , coherent, cooperative,well oreinted to time place person

Speech normal

Behaviour normal

Memory intact 

Intelligence normal 

CRANIAL NERVE EXAMINATION

  -OLFACTORY-normal

 - optic : normal visual field

-oculomotor,trochlear,abducens facial-intact

- vestibulocochlear- intact

 - glossopharyngeal -intact

  - vagus-intact

  -accesory spinal ganglion nerve intact

  - hypoglossal intact

Sensory system:

-fine touch: intact

-pain: normal 

-temperature  - normal

- vibration -normal

-stereognosis- normal

-two point discrimination-present

Motor system examination

Nutrition -

U/L.         R.             L

            Normal.    Normal

L/L.     Normal.       Normal

TONE:

        U/L.                     R.          L.

   

                         Normotania. Narmotonia 

         L/L 

                      Normotonia.  Normotonia 

    

  

POWER.   :-         RIGHT.           LEFT.

SHOULDER

flexion  :               5/5    5/5

 Extension        5/5.  5/5

Abduction     5/5.  5/5

Adduction         5/5.    5/5

Internal rotation 5/5.   5/5

External rotation    5/5.   5/5

Elbow:5/5.    5/5

Flexion.     5/5.   5/5

Extension:5/5.   5/5

Wrist:5/5.  5/5

Flexion:5/5.   5/5

Extension:5/5.   5/5

Abduction : 5/5.   5/5

adduction:5/5.   5/5

Hip

Flexion:5/5.    5/5 

Extension.  5/5.   5/5

Abduction:5/5.   5/5

Adduction 5/5.    5/5

Internal rotation:5/5.    5/5

External rotation.  5/5.    5/5

Knee 5/5.     5/5

Flexion 5/5.    5/5

Extension.   5/5.   5/5 

Ankle.  5/5.     5/5

Plantarflexion:.   5 /5.    5/5

Dorsiflexion.     5/5.  5/5

Toe.   5/5 5/5

Movements:5/5

REFLEXES: 

Corneal present 

Conjunctival  present 

Abdominal: present 

Plantar: present 

https://youtube.com/shorts/z3fpUJUdcAY?feature=share

DEEP REFLEXES:

Biceps : 5+.   5+

Triceps 5+.   5+

Knee : 5+.      5+

https://youtube.com/shorts/7sQEvOZOprc?feature=share

Ankle: 5+.   5+

CEREBELLAR 

NYSTAGMUS absent

DYSADEADOCHOKINESIA absent 

https://youtube.com/shorts/Yh8K0g4OBk4?feature=share

FINGER NOSE tip- normal

Rhomberg sign  

Rebound phenomenon present

Heel to knee intact 

https://youtube.com/shorts/f9nrPRcUWtE?feature=share

Gait :- normal

 Meningial sign 

 Kernigs sign negative 

Brudzinski sign negetive

https://youtube.com/shorts/7sQEvOZOprc?feature=share 

 

Cvs- s1 s2 heard ,no murmur,apex beat at mid clavicular line at 5 th intercoastal space.

Respiratory system 

I: Chest bilaterally symmetrical, all quadrants

moves equally with respiration

P: Trachea central, chest expansion normal

P: Resonant

A: B/l equal air entry

B/I VBS

no added sound

Per. Abdominal examination :-

I normal

P soft non tender

No organomegaly

Investigations:- on 25 th November

On 28 th November

Differential diagnosis:- 

Right hand complex partial seizures due to old infract ?

Neurocysticercosis?