Case history - 8

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A 50 year old male patient came to casualty with chief complaint of seizures.

History of present illness : 

Patient was apparently asymptomatic  6 months back then he developed  hemiplagia,  deviation of mouth  to right side. 

2 months back he got admitted in hospital because of altered sensorium.

2 days back patient experienced two episodes of seizures .

First  episode was in the morning  at around 7:30 am .

Second episode was on the same day at around 1:30 pm in afternoon after which patient was admitted in the hospital.

Past history : 

History of diabetic mellitus  since 1 year.

History of hypertension since 3 months.

Patient has a history of accident 4 years back. 

No history of fever, headache.

No history of CAD, asthma , tuberculosis.

Family history : 

No history of similar complaints in the family.

Personal history : 

Appetite - normal 

Diet - mixed 

Bowel and bladder movements - regular 

Sleep - adequate 

General examination: 

Patient was conscious , coherent but not cooperative.

Pallor - absent 

Cyanosis - absent 

Icterus - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Edema - absent 

VITALS : 

Temperature - Afebrile 

Respiratory rate - 18 / min 

Pulse rate - 110/ min 

Blood pressure - 160/100 mmHg 

SpO2 -98 % 

GRBS - 107 mg % 

SYSTEMIC EXAMINATION: 

Cardiovascular system : 

No thrills 

S1 S2 heard 

Respiratory system :

No dyspnea 

Bilateral air entry - positive 

Abdomen : 

No tenderness 

No palpable mass 

No free fluid 

No bruits 

Central nervous system : 

Level of consciousness - conscious 

Deviation of mouth to right side 

Investigations : 

Provisional diagnosis : 

Seizures 

Left sided  hemiplagia 

Patient is known case of diabetes, hypertension .

Treatment : 

Inj Levipil 

Inj Lorazepam 

Tab Metformin 

Tab Telma 

Inj Loraz