21 year old female with seizures

MEDICAL CASE

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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

CASE DISCUSSION:

A 21 years old female P2L2 delivered 10 days back NVD - live male baby of 3.5kgs, housewife by occupation brought with complaints of 

Headache since Morning 

1 episode of involuntary movements at 12am

HOPI:

Patient was apparently asymptomatic 1 day back then complained of headache since morning, 1 episode of involuntary movements pattern of tonic clonic seizure at around 12am today and second episode of tonic clonic seizures at 12.30 am at kims and a episode of vomiting next day

H/o frothing from mouth 

No H/o tongue bite

No h/o involuntary micturition and defecation 

Episode lasted for 2 mins

Post ictal confusion present.

PAST HISTORY: Not a k/c/o DM,htn,tb,asthma,epilepsy 

PERSONAL HISTORY:

She is Married

She consumes 

Mixed diet 

sleep is adequate 

Appetite normal

bowel and bladder movements are regular

MENSTRUAL HISTORY: 

Age at menarche:12 years

Cycle: 30/5 days, Normal flow.

OBSTETRIC HISTORY:

Age at Marriage:19 years

1st pregnancy: conceived after 1 month of pregnancy,NVD, 

2nd pregnancy: conceived after 6 months of 1st pregnancy NVD.

FAMILY HISTORY:

No similar complaints in family 

CLINICAL IMAGES:

General examination:

On presentation: Patient conscious, coherent, cooperative, well oriented to time place and person.

Pallor present 

Vitals:

Bp:120/80

Pr:130bpm

Rr:24cpm

Temp:98.2f

Grbs:84mg/dl

Spo2:97%

SYSTEMIC EXAMINATION:

CVS:s1,s2 +

Rs:bae+

P/a: size of uterus:corresponding to 12wks 

CNS: b/l pupils NSRL

              R L

Tone: N. N

Power: 5/5. 5/5                  

Reflexes : B T S A K P 

           R: + + + + + Flexion 

           L : + + + + + Flexion

No neck stiffness 

Kernigs negetive 

Brudzinski negetive 

INVESTIGATIONS:

DIAGNOSIS : Seizures under evaluation.

TREATMENT:

Presently: had a 2nd of episode of involuntary movement pattern of tonic clonic seizure at 1:15am lasted for 2 mins 

H/o frothing from mouth

No h/o tongue bite

No h/o involuntary micturition and defecation 

Post ictal confusion present.

Plan at the time of episode: 

2mg lorazepam IV

Levipill 25mg in 100ml NS IV

25 D IV

2D ECHO: https://youtube.com/watch?v=kHE1-A6LMrA&feature=share