Case Study Seizure Explained for Students (Easy Guide)
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Original Question
Case Study: Seizure CC: Seizure What history questions will you ask specific to the chief complaint? HPI: A 21-year-old Caucasian male, presents to your office with complaint of jerking of his extremities and loss of consciousness. He states that a month ago, he was eating at a restaurant with his girlfriend and he fell out of his chair jerking and lost consciousness. His girlfriend wanted to take him to the ER, but he did not feel that was necessary. He is now concerned because the same thing happened to him yesterday when he was playing cards with his friends. He describes a heightened sense of smell and increased nervousness prior to the onset of jerking. He was incontinent and fatigued after both episodes. He had just lay down for a few hours before and felt fine before the event. A bystander told him that he was unconscious only a few minutes or two. The jerking movements were on both sides equally. There is no family history of epilepsy. Past medical history: Broken leg at 10 years old, no history of head injury, stroke or meningitis. Family history: Mother: migraine HA, Grandmother: HTN. What will you focus you physical examination on? What specific tests will you assess? Pertinent physical findings: VS: Ht 6’4″ Wt 221, BMI 27, T 98.2, HR 66, R 14, BP 122/82 General Appearance: Alert and oriented x4, well groomed, well nourished. Coordinated movements with stable gait. HEENT: Head: normocephalic, without trauma. Face: symmetrical, smiling. PERRLA, EOMs intact, Funduscopic: optic discs sharp, well-defined, cream color, no exudates or hemorrhages. Ears: TMs gray with distinct cone of light. Nose: clear. Throat: oral mucosa pink, no lesions, tonsils 2+, Neck: no cervical lymphadenopathy or carotid bruits. Neck supple. Thyroid WNL. Heart: RRR, no S3 or S4, PMI 5th ICS-MCL, radial, pedal and femoral pulses 2+ and equal bilaterally Lungs: Clear to auscultation Neurological: CN II-XII grossly intact, DTR 2+ bil symmetrical, muscular strength intact bil, no atrophy or tremors, Romberg negative, sensation intact to light touch and pinprick, able to heel-to-toe walk. Would you order any diagnostic tests at this point? Rationale. Diagnostic Tests: HCT 46%, HGB 15.0 g/dl, RBC 4.9 million/ul, MCV 90 u3, MCH 30 pg, MCHC 34%, WBC 7200/ul, ALT 12 U/L, AST 17 U/L, toxicology screen negative. EEG: Spiked wave showing generalized abnormality CT Head: Negative What is your diagnostic impression? What are your differentials? What is your plan of care for this patient?
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