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CASE PRESENTATION:
A 33 year old female,resident of narketpally, housewife by occupation came with the chief complaint of Headache and neck pain since 3 days.
And. involuntary movements of all four limbs since evening 7:00 pm
HOPI:
Patient was apparently asymptomatic 3 days back, then she developed headache, associated with neckpain. Pain was over occipital region , dragging type, constant throughout the day. Associated with tingling of lower and upper limbs. Also associated with blurring of vision.
No diurnal variation, vomitings, neck stiffness, fever , diplopia.
-H/o fall at 5 pm, with black outs, giddiness, with loss of consciousness chest pain for 10 mins. Regained conscious and tried to walk.
At 8pm, they went to nearby rmp doctor and they were given medication.
-At that point She had an episode of seizures at 9pm with tonic clonic movements of right upper and lower limbs with frothing from mouth. Loss of consciousness for 10 mins.
Seizures were preceded by chest pain, palpitations, sweating, visual disturbance,
No nausea, vomiting, sphincter incontinence, breathing pattern abnormality.
No tongue bite, deviation of mouth, uprolling of eye balls.
Recovered spontaneously with confusion and residual weakness(?Todds paralysis)
There was an another episode of seizures after 10mins lasting for 10mins with generalized tonic clonic movements of all the 4 limbs. And brought to our hospital with on going seizures.
Total no of seizures: 7-8 episodes in the hospital stay from 9:00 pm to next day morning 8:00 am each seizure episode lasting for 1-2 minutes with no complete regain of consciouness in between the seizure interval
Sensorium between episode was drowsy but arousable.
No sustained injuries.
No speech abnormality.
PAST HISTORY:
K/c/o epilepsy. She had seizure activity 5 years ago and was under ayurvedic treatment for 1 year and stopped.
No h/o hypertension, diabetes mellitus, chronic kidney disease, chronic heart disease, bronchial asthma, tuberculosis, thyroid disorders.
No h/o previous surgeries and blood transfusion.
PERSONAL HISTORY:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder movements: regular
No addictions
FAMILY HISTORY:
No similar complaints in the family
DRUG HISTORY:
Not allergic to any known drugs.
MENSTRUAL HISTORY:
Age of menarche: 12 years.
She bleeds for 4 days for every 30 days. Cycles are regular with no pain and clots.
GENERAL EXAMINATION:
Patient is in drowsy but arousable.
Patient is moderately built and moderately nourished.
No signs of pallor, icterus, cyanosis, clubbing, kilonychia, generalised lymphadenopathy, bilateral pedal edema.
VITALS:
Temperature: afebrile
Pulse rate: 63 beats per min
Respiratory rate: 36 cycles per min.
Blood pressure: 150/100 mm of hg
Spo2 : 98% at room temperature.
Grbs: 106 mg%.
SYSTEMIC EXAMINATION:
-CNS:
-Higher mental functions:
drowsy but arousable , normal speech.
- Spinomotor: No wasting / thinning of muscles. No pain,fatique,fasciculations.
Right. Left
Bulk. Normal. Normal
Tone. Normal. Normal
Power.
UL. 4/5. 4/5
LL. 4/5. 4/5
Reflexes-
Superficial:
Corneal : +. +
Conjunctival: +. +
Deep tendon reflexes
Right. Left
Biceps. ++. ++
Triceps. ++. ++
Supinator. ++. ++
Knee jerk. +++. +++
Ankle. ++. ++
Plantar. Flexor. Flexor.
- Sensory system: no sensory deficit.
- Cranial nerves :
1: no alternation in smell
2: blurring of vision present, able to differentiate colour.
3;4;6: no double vision . Able to move eyes in all directions
5: normal chewing of food . Sensation over face present
7: eye closure present
8. Hearing present , no tinnitus .
9,10. No difficulty in speech.
11. Normal neck movements in all directions.
12. Tongue rolling present.
-Cerebellar functions: Normal.
-ANS : Able to feel bladder fullness. Regular bowel movements, giddiness on waking up in the morning present. No sweating and palpitations.
-Meninges : No fever , nausea , vomiting or stiffness of neck.
-Perabdominal examination:
Shape of abdomen - scaphoid and soft
No tenderness and local rise of temperature
No palpable mass,
Hernial orifices: normal
No free fluid and no bruit
Liver and spleen: not palpable
Bowel sounds: heard and normal.
-Respiratory system examination:
Position of trachea: central
No dyspnoea and wheeze
Bilateral air entry present.
normal vesicular breath sounds heard.
No adventitious sounds.
Cardiovascular system examination:
S1 and S2 heard, no murmurs.
Based on above findings , the following investigations were sent.
1) hemogram
2) liver function test
3) kidney function test
4) complete urine examination
5) CT scan- brain.
6) ECG
7) thyroid function test.
8) fundoscopy
9) serum magnesium
10) Random blood sugar
11) EEG
Fundoscopy : normal
EEG : normal
PROVISIONAL DIAGNOSIS:
Recurrent epilepsy -? focal seizures progressed to GTCS.
K/C/O epilepsy-non compliant to medication.
MANAGEMENT:
1) Inj. Levipil 2gm in 100ml NS / IV / stat.
2) Inj. Lorazepam 2cc/ IV/ stat , as seizures repeated
4) Half hourly bp monitoring and head end elevation.
5) Inj. Eptoin 800mg in 100ml NS / IV/ stat over 30 mins. Followed by Inj EPTOIN 400 mg in 100 ml NS /IV / stat over 20 mins
6) Inj. MgSO4 1amp in 500ml NS / IV over 2 hrs
7) Inj. Optineuron 1 amp in 100ml NS/ IV OD.
8) Inj. pcm 500mg im sos.
9) Inj. Pan 40mg IV OD.
10) Inj. Zofer 4mg IV TID.
11) IVF DNS @ 75ml per hour.
EEG done showing no abnormality
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