A 22yr old primigravida...
CASE REPORT ::
A 22 year old primigravida with gestational age of 10 weeks who is housewife who is a resident of munugodu was brought with
CHIEF COMPLAINTS :
Muscle spasms involving both upper , lower limb and neck since yesterday evening.
PAST HISTORY ::
Not a known case of DM, HTN, Tuberculosis , asthma.
No history of blood transfusion and major surgeries.
PERSONAL HISTORY :
Appetite :normal
Diet : mixed
Sleep : adequate
Bowel and bladder : regular
No addictions.
No known drug and food allergies.
FAMILY HISTORY :
No history of epilepsy in the family.
GENERAL EXAMINATION :
Patient is conscious coherent cooperative and well oriented to time place and person.
Consent of the patient and attenders was taken and examined in a well lighted room.
Patient is moderately built and nourished.
Pallor - Present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Edema - absent
VITALS :
Temperature : afebrile
Pulse rate - 78 beats per minute , normal rhythm and character and normal vessel wall , no radio- radial and radio femoral delay.
Respiratory rate - 18 cycles per minute
B.p - 110 / 70 mm of Hg in right arm.
SYSTEMIC EXAMINATION :
CNS
E4V5M6
Higher mental functions are normal.
Cranial nerve examination is normal.
Motor system : no abnormality detected.
Sensory system : no abnormality detected.
Cerebellum : no abnormality detected.
Pupil : bilaterally reactive .
CVS :
S1 , S2 Heard , no murmurs
RESP. SYSTEM :
Bilateral air entry present.
No vesicular breath sounds .
P/A :
Soft and non tender .
No organomegaly.
Bowel sounds heard .
Gravid uterus not palpable.
CLINICAL DIAGNOSIS :
Known case of Generalised tonic clonic seizures.
? Hypocalcemia.
INVESTIGATIONS :.( Done outside on 4 days back ).
PROVISIONAL DIAGNOSIS :
EPILEPSY.
? HYPOCALCEMIA .
TREATMENT : ( on 01/04 /22)
INJ LEVIPIL 500mg IV BD
INJ OPTINEURON 1amp in 100ml NS IV OD
INJ PAN 40mg IV OD
(Plan for EEG, 2D ECHO,
USG obs scan with full bladder.)
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