AN 85 YEAR OLD PATIENT WITH SEIZURES FOLLOWING FEVER

January 02, 2023

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through a series of inputs from an available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient-related online learning portfolio and your valuable inputs on the comment box.

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 to come up with a diagnosis and a treatment plan.

CHIEF COMPLAINTS:

• Fever since 3 days
• 2 episodes of involuntary movements of upperlimb and lower limb in the past 3 days
• Loose stools since 1 day

HOPI:

The patient was apparently asymptomatic 3 days ago, then he developed a fever, which was of high grade, associated with chills, after which he developed seizures lasting for 2 minutes, associated with postictal confusion for 5 minutes. The seizure was accompanied by involuntary micturition and defecation. He consulted a local RMP and was treated with unknown medications.

The next day, he had another episode of fever followed by a seizure lasting 2 minutes and postictal confusion lasting 5 minutes, associated with involuntary micturition and defecation.

On the 3rd day of showing symptoms, he came to our hospital with passage of loose stools which are non blood stained, non foul smelling, sticky.

PAST ILLNESS:

Not a known case of HTN, DIABETES, ASTHMA ,TB, EPILEPSY, CVD

PERSONAL HISTORY:

No addictions

Appetite: normal

Diet: mixed
Bladder: unable to hold urine
Bowel: loose stools
Sleep: regular

GENERAL EXAMINATION:

The patient is conscious, coherent and cooperative, moderately built and nourished, and is well oriented to time, place and person.

Pallor -Absent
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy- Absent

Vitals:
Pulse rate: 92 bpm
Temp: 99°F
RR: 21 cpm
BP: 100/70 mmHg

SYSTEMIC EXAMINATION:

• CVS
s 1 s 2 heard
no added sounds

• RESPIRATORY SYSTEM

Position of trachea central

chest symmetrical

Chest expansion symmetrical

R L

percussion resonant resonant

Auscultation normal normal

• Abdominal examination

abdomen is soft ,Non tender , no Ascites

• CNS Examination
Higher mental function : intact

Cranial nerve examination : normal
Motor system:

•Muscle Bulk. R L

Inspection. Normal Normal

Palpation. Normal Normal

•Muscle tone

upper limb Normal Normal

lower limb Normal Normal

•Muscle power

upper limb 5/5 5/5

lower limb 5/5 5/5

•Reflexes

Biceps ++ ++
Triceps. ++ ++
Supinator. ++ ++
Ankle ++ ++
Knee ++ ++
Plantar ++ ++

INVESTIGATIONS: