50 YRS OLD MALE PATIENT WITH SEIZURES

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I've 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 a diagnosis and treatment plan.

CASE:

A 50 yr old male patient  who is resident of west bengal came to the opd with chief complaints of sudden fall it is followed by loss of consciousness and involuntary movements of both upper and lower limbs  which lasts for 15 to 20 min  since 18 yrs . The episode of  involuntary movements occur 2 to 3  times a month .Which is associated with frothing .

And also after regaining consciousness after 15 to  20 min  associated with right side headache which relieves on taking medication ,he is able to recognize everyone after the episode .He feels very  uncomfortable on the day of episode .There is loss of appetite also .

There is no history of trauma.

No history of fever,vomitings, slurring of speech .

No history of deviation of mouth.

No history of uprolling of eyes , tongue bite.

No history of fever .

Past history:-

Similar compalints since 18 yrs.

Not a known case of DM,HTN,Thyroid 

History of taking medication - phenytoin 100 mg since 1 yr .

There is history of loss of tooth due to fall in the past.

Family history:-

No similar compalints in the family.

General examination:- 

Patient is conscious,coherent, cooperative.

Vitals:-

Temp- afebrile

BP- 110/70 mmHg 

PR- 85 bpm

RR- 18cpm 

Spo2- 98%on room air

Investigation:- 

TREATMENT:-

* Tab. Zincovit 

                  *Tab. Phenytoin 100 mg 

PROVISIONAL  DIAGNOSIS:-  

Generalised tonic clonic seizures.