A 36 year old male presented to opd with seizures.

 History of present illness: On 24th a 36 years old male patient cable operator by occupation presented to general medicine opd with seizures at 3am. The patient was apparently asymptomatic until 2am then he developed seizures which occurred in 4 episodes with an interval of 5-10 minutes, each episode lasting for 2 minutes, without postictal confusion. The seizures were generalized and with vigorous contractions and relaxations. Just before the occurrence of 1st episode patient experienced tightening of muscles in the limbs and lifting of the lower limbs.

3 years back he was diagnosed with diabetes type 2 and is on medication. When RBS was done immediately after he came to hospital it was 559 and the BP was 160/100 mm Hg. 

Past history: No similar complains in the past. In 2019 there was mild head trauma and swelling which subsided after 3 days.

Not a known case of Hypertension, Asthma, thyroid, epilepsy.

Personal history: Patient is a cable operator by occupation. He wakes up by 9 am and goes to his job, takes lunch by 2pm and comes home after the work is done sometimes takes rice for dinner . His appetite is normal, sleep is adequate,bowel and bladder are regular, and he occasionally consumes alcohol. The day before the patient had seizures he consumed 180ml of wine and fruits  (apple and Pomegranate). 

Family history: Patient's father is a known case of diabetes and Hypertension. No similar complains in the family.

Drug history: k/c/o diabetes, and is on medication metformin 500mg +glimipiride 1mg since 3 years.


General examination: 

Pallor: absent

Icterus :absent 

Cyanosis: absent 

Clubbing:absent 

Lymphadenopathy: absent 

Edema: absent 

vitals: 

BP:

Temperature:afebrile

Respiratory rate: 16cpm

Heart rate:78bpm


Systemic examination:

CNS: 

1. HIGHER MENTAL FUNCTIONS:

Conscious, coherent and Cooperative 

Appearance and behaviour:

Emotionally stable 

Recent, immediate ,remote memory intact 

Speech : comprehension normal, fluency normal ,No repeatitions .

Right handed individual .

2. CRANIAL NERVE EXAMINATION: 

 

*Olfactory: Normal


*Optic nerve : visual acuity : CF 

Pupil: sluggish pupillary response to light 


*3,4,6 : normal , ocular motility is present in all directions.


*Trigeminal : normal sensory and motor 

 

* Facial nerve : forehead wrinkling present

                             Able to close eyes, able to blow cheeks.


* 8th nerve : decreased hearing.


* 9 and 10 nerves: normal


*11th nerve : SCM, trapezius : normal.


*12 th nerve : no deviation of tongue, no fasiculations.

MOTOR EXAMINATION :

 

Bulk:  normal 

Tone       :          Right                    Left

Upper limb         Normal          Normal 

Lower limb 

Power:       Right                            Left 

 Upper limb  4/5                          4/5

Lower limb   4/5                           4/5

Reflexes :          Right              Left 

 

Corneal           present             present 

Conjunctival    present            present 

 Deep reflexes  

Biceps + +

Triceps + +

Knee + +

Ankle + +


SENSORY FUNCTIONS 

SPINOTHALAMIC TRACT 

Pain, temperature, pressure- intact in all limbs 

Posterior column :

 Fine touch,vibration, proprioception are intact

CEREBELLAR FUNCTIONS : 

Titubation: absent 

Nystagmus : absent 

Dysmetria : absent 

Dysdiadochokinesia : absent 

Intension tremor : absent 

No signs of cerebellar dysfunction.

CVS : S1 S2 ++ no murmurs heard.

RESPIRATORY SYSTEM: Normal vesicular breath sounds heard.

ABDOMEN: Soft non tender.


Investigations: 

MRI: 

Impression: Posterior predominant subcortical FLAIR  hypointensity and cortical hyperintensity in bilateral cerebral hemispheres,more on the left side.

Bilateral symmetrical periventricular hyperintensities- Chronic small vessel ischemia. 

Fundus examination:

ECG: 

Provisional diagnosis: Hyperglycemia induced seizures with microvessel thrombi due to Hypertension and diabetes. 

Treatment: 

Inj HAI 1ml 40units +39ml NS

Inj levipil 500mg IV BD 

Inj Thiamine 200mg in 100ml NS IV TID

Inj Zofer 4mgIV SOS 

Inj pan40mg IV OD 

Tab Ecospirin 75mg PO OD

Tab atorvas 20mg PO OD .
















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