50/F with Focal seizures and impared awareness
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50 year old housewife presented to our opd with the complaints of
1 episode of loss of consciousness 3 days back
Headache and generalised weakness
She studied till her 4th grade and got married to a farmer at the age of 17 years. She gave birth to 4 children via normal vagina delivery and got operated for hysterectomy around 25 years back. Her elder son is unemployed and is an alcoholic where as the younger son is a daily wage laborer. Both of her daughters are married.
On further questioning her brother revealed that the patients behavior has changed ever since she got married.
Her brother reveales his brother in law to be an abusive husband. He says his brother in law often beats her so much to an extent that she would often have nose bleeds. She covers her bruises and takes pain killers frequently for the pain.
On a daily basis, both the husband and wife quarrel alot. She has become an aggressive individual herself and often bears her children. She shouts at her children and son in laws frequently.
Her brother reveals that during arguments she has this typical behavior of pulling her hair and biting them.
He also reveals that she has been stressed lately as her elder son is unemployed and has been drinking alcohol frequently and because of frequent arguments at home he left their house in search for a job. She even isn't on good terms with both her son in laws who consume alcohol frequently and argue back with her.
6 months back while she was working in filed she was unconscious and family members saw this and took her to tree shade and gave some fluids and took to near by hospital then she was told to have high blood pressure for which she used tablets for few days and then stopped
15 days back her younger daughter gave birth to a baby boy and has been staying at their place ever since. Since then she has been having heated arguments with her daughter and son in law asking her daughter to change her husband's behavior and habits.
3 days back while sitting on a chair and eating a papaya and having a casual conversation with her husband, she suddenly had a loss of consciousness lasting for 5 minutes. After regaining consciousness she was given a glass of water with sugar. She herself got up and got ready to go to the hospital.
She was taken to a local hospital where in they were told that she was a hypertensive and had hypothyroid as well.
She was given IV fluids along with Tab Telma AM and Multivitamins.
At around 4pm at our OPD, she had another episode of loss of consciousness and micturated in her clothes after which she was rushed to casualty. At the casualty she had involuntary movements of her right upper and lower limb along with uprolling of eyes.
She was given 4 cc Inj lorazepam and she was in post ictal confusion for 1 hr
She is conscious and not answering questions though has been involving in conversations with her brother
Her
PR - 95 bpm
BP - 140/80
Afebrile
General examination:
Pallor absent and
No icterus
No cyanosis ,clubbing lymphademopathy,Edema.
Systemic examination:
Cvs apex beat in 5th ICS medial to midclavicular line
No murmers
RS: BAE + nvbs
P/A soft ,nontender,bowels sound heard,
CNS
HMF- patient conscious
Speech : slurred
Memory recent and remote : Intact
Lobar function tests
Insight +
1.Frontal:social behaviour:normal
language:normal
micturation:normal
2.parietal dominant: language normal,
ideational apraxia:present
right left orientation: present
finger agnosia : present
simple : present
complex calculations lost
3.parietal non dominant
constructional skills:?
4.Temporal:
memory and language:normal
5.occipital
visual memory:normal
prosopagnosia:absent
cranial nerves-1st normal
2nd Counting fingers at 6mts both eyes normal
rt lf
3rd,4th,6th
pupil size. N N
DLR/CLR. N. N
NO pstosis, nystagmus.
5th sensory normal
motor normal
reflex corneal normal,conjuctival present
7th motor nasolabial fold normal
Slight deviation of mouth to right
reflex corenal and conjuctival normal +
secretomotor moistness of eye and tongue normal,buccal mucosa normal
8 the nerve:Rinnes and Weber's Normal
9and 10 th nerve: uvula centrally placed
11 th nerve: trapezieus normal sternocleidomastoid normal
12 th nerve: tongue tone normal, no wasting, no fibrillations,no deviation of tongue
MOTOR SYSTEM
Bulk: Right. Left
Normal. Normal
Tone: ul. Normal. Normal
LL. normal normal
Power UL prox 5/5. 5/5
distal 5/5. 5/5
LL.prox 5/5. 5/5
distal 5/5. 5/5
Reflexes.
Superficial reflexes
Right. Left
Corneal. Present present
Conjunctival Present Present
Abdominal. Present Present
Plantar mute mute
Deep tendon reflexes
Right. Left
Biceps. 2+ -
Triceps. 2+ 2+
Supinator - -
Knee - -
Ankle - -
SENSORY SYSTEM Normal
CEREBELLUM
Intensional tremors - absent
Pendular knee jerk - absent
Coordination tests
Dysdiadochokinesia absent on left side
Finger nose test : normal
Rombergs: negative
MENINGIAL SIGNS
Neck stiffness - absent
Kernigns sign - negative
Brudzinkis sign - negative
Fundoscopy: Normal Fundus
Absent left ICA
Diagnosis : Focal seizures with global impairement secondary to ? Primary vasculitis
With k/c/of HTN and Hypothyroidism
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