A 50 YEAR OLD MALE WITH BLACKOUTS
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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.
• 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
• 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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