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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
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This is a case of a 25 year old male who came with an episode of seizures 25 days ago
HOPI:
Patient was apparently asymptomatic 12 years back then he developed an episode of seizure which is sudden in onset. He experienced pain as well and described it that it was so severe he felt like someone was twisting and chopping his hand. He then unconscious,the whole episode lasted for 3-5 minutes, associated with tongue biting. The patients attender confirmed this,
Not associated with frothing from mouth, uprolling of eyes , postictal confusion,and autonomic symptoms like urination and passage of stools during seizure episode.
After the first episode he took some ayurvedic medicine for 2-3 months but he got another similar episode of seizures ,then he went for another ayurvedic medicine and used it for 2 months but he again experienced similar episode,after these 3 episodes he came to kamineni hospital .
In kamineni hospital they diagnosed it as Right complex partial seizures and gave Tegretol and
Zincovit ,he continued to use this medication for 3 years with regular follow up of once in three months .He stopped the medication by himself without any advice From his doctor .
After this 12 years of seizure free period he got 4 th episode 25 days back .
On the day of 4th episode he woke up at 7 o clock and ate rice at 9 o clock went to farm to work ..at around 12 o clock he climbed palm tree for toddy extraction but he felt a bad aura that he is going to have seizures as some pain started in his right hand then he immediately came down and sat in a safe place ,then same like first episode he experienced pain which is increasing as it radiating to shoulder followed by a period of unconscious .There were no one around him at that time of incident ,he regained his consciousness and went home ,after two days went to rmp doctor he gave an injection and tablets ,due to financial problems he didn't visit hospital immediately after seizure episode .
Daily routine
He wakes up at 7 am and freshens up. He has his first meal of the day which consists of rice. And then he goes to the fields and cultivates cotton.
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