A 22 year old female with ataxia
04.02.2022
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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.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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.
Maheshwari Jagathkari
Roll no. 57
Case report
A 22 year old female presented with ataxia and generalized weakness since 5 days.
She also complained of nausea and vomiting sensation, decreased appetite.
The patient was apparently asymptomatic 15 years back that is at 7 years of age she developed high grade fever associated with vomitings during which she had her first episode of seizures which were sudden in onset lasting for 5 min for which she was taken to a hospital and she got recovered on medication.
She continued to take medication due to which there were no further seizure attacks so she stopped taking medication after which -
At 10 years of age -she had another episode of seizures for which she was treated and again stopped taking medication due to which -
At 11 years of age - she had an another episode of seizures for which medication was given .
She continued to take medication till 18 years of age.
At 18 years of age she got married which is non consanguinous, following which she stopped taking medication for 6 months.
After 6 months of marriage she conceived, during which she had 4th episode of seizure for which she was treated with antiepileptics .A healthy baby girl was born.
She conceived again after few months during the pregnancy she had an another episode for which she was treated. A healthy baby boy was born.
Since then she has been taking
Phenytoin-100mg B.D
5 days back she came to our hospital for a routine follow up, she was prescribed with Leviteracetam.
PAST HISTORY -
There is no history of diabetes, hypertension, tuberculosis, thyroid abnormalities.
No significant family history related to seizures.
Patient takes mixed diet, decreased appetite since 5 days, regular bowel and bladder movements, sleep is disturbed, without any addictions.
GENERAL EXAMINATION- Patient is conscious, coherent and cooperative, well oriented to time, place and person.
Pallor is present with no features indicating the presence of icterus, cyanosis, clubbing, lymphadenopathy, generalized edema.
VITALS
Pateint is afebrile with 110/80mm Hg of blood pressure, respiratory rate being 20cpm, pulse rate of 80bpm.
Systemic examination revealed
CVS- S1 and S2 heart sounds heard.
RS- Bilateral air entry is present, normal vesicular breath sounds heard.
Per abdominal examination revealed soft non tender abdomen.
No focal neurological deficits noted.
On examination she has gum hyperplasia, ataxic gait.
INVESTIGATIONS-
ECG
The gum hyperplasia, ataxia and chronic history of phenytoin usage is suggestive of chronic phenytoin toxicity
Day 1
SOAP notes
S - Giddiness, difficulty in walking decreased. No seizure episodes.
O - vitals stables, no nystagmus, ATAXIA present.
A - Cerebellar atrophy 2to Phenytoin toxicity
P - levipil 250mg BD, stopped phenytoin
Follow up:
No swaying, no giddiness
Discussion
Phenytoin (diphenyl hydyantoin) is a sodium channel blocker.
Mechanism of action of phenytoin
Side effects of phenytoin
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