A 50 YEAR OLD MALE  WITH BLACKOUTS

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.


• 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.

With involuntary movements of both upper limb and lower limb during the blackout sometimes

After waking there is right unilateral head ache

He also has no recollection of the incidents on waking. 


• HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 32 years back then he developed loss of consciousness while lying on the bed at night and not associated with involuntary movements . 

Since then he had several episodes of loss of consciousness : 2 to 3 attacks per month,sometimes associated with involuntary movements. And also right unilateral head ache.

Sometimes due to hard falls there was fall of teeth(3 upper incisors and a canine) once, lacerations and contusions on the body.

Involuntary movements of limbs 

Loss of consciousness is also associated with frothing

not associated with tongue bite, involuntary micturition, involuntary defecation. 

They consulted a few doctors but they found no improvement. 

A year back they consulted a neurophysician, he Prescribed PHENYTOIN SODIUM 100mg(OD) which helped reduce the frequency of the LOC episodes and the head ache.

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 they consulted the same doctor and the dose of phenytoin was increased to 300mg. 

After that episode, he has difficulty in raising both upper limbs above the shoulder and also 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 yr ago- Doctor prescribed  PHENYTOIN SODIUM 100mg(OD) which reduced frequency of loss of consciousness and headache.

One month ago there was unconscious clothes removal episode after which the dose of phenytoin was increased to 300mg(OD)PAST HISTORY

Not a known case of HTN,DM,ASTHMA,TB

Known case of  EPILEPSY 


• PERSONAL HISTORY

Diet:  mixed

Appetite : Normal

Sleep: adequate

Bowel and bladder habits : Regular

Addictions : Alcohol occasionally. Non smoker and Chews supari (Areca nut) everyday since more than 35 years. 


• FAMILY HISTORY

No relevant family history 


• GENERAL EXAMINATION

Patient was conscious,coherent ,coperative

Moderately build and moderately nourished

Well oriented to time, place

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 

RS - NVBS +

PA- 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



INVESTIGATIONS

    After hard fall 



Hemogram


Complete urine examination



                            Blood sugar



Blood urea



Serum creatinine


Serum electrolytes


Liver function tests





                                  ECG



Chest XRay




• 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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