A 22 year old female with ataxia
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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.
Roll no - 58
Janhavi Virani
A 22 year old female presented with
Ataxia ( impaired coordination) and generalised weakness since last 5 days .
HOPI -
Patient was apparently asymptomatic 15 years back when she was 7 years of age .
At 7 years of age -
got high grade fever associated with vomiting during which she got her first seizures (febrile) which was sudden in onset lasted for 5 mins then she was taken to hospital in Hyderabad.
She was treated.
She continued to take her medication which reduced the seizures so she stopped taking further medication.
Then …
At 10 years of age -
She had an another episode of seizures. She was treated for it . Later again she stopped taking medication.
Then ….
At 11 years of age -
She again had an episode of seizure for which she took tablets and got better. She continued her medication till she was 18 years of age .
At 18 years of age -
She got married . Marriage is non consanguineous following which she stopped taking medication for 6 months .
1st pregnancy -
After that she conceived got pregnant during her gestation she didn’t have episode of seizure as she was taking anti epileptic which is safer in pregnancy. We came to this conclusion as she delivered a healthy baby (daughter) at the age of 19 years .
2nd pregnancy-
she had an episode of seizure so she started taking atiepileptic that is phenytoin. According to attender her 2nd child (son ) is healthy .
Since then she’s been taking Phenytoin .
Phenytoin - 100mg bd
PAST HISTORY-
Not a known case of DM / HT / Asthma/ tuberculosis/ thyroid abnormalities.
FAMILY HISTORY-
No relevant family history.
PERSONAL HISTORY-
Diet - mixed
Appetite- Decreased since 5 days
Sleep - Disturbed since 2 days
Bowel and bladder- regular
No addictions
GENERAL EXAMINATION-
Pallor- yes she is mild anemic
Icterus -absent
Cyanosis- absent
Lymphadenopathy- absent
Edema - absent
VITALS -
Temp - afebrile
RR - 18cpm
PR - 75bpm
Bp - 110/80mmhg
SYSTEM EXAMINATION -
CVS - S1 and S2 heard
CNS - no abnormalities detected ( Tone , Power , Reflexes )
No focal neurological deficits.
Respiratory- bilateral air entry present , normal vesicular breath sounds are heard .
Per abdomen - soft , non tender
On examination she is found to have Gum Hyperplasia.
INVESTIGATIONS-
ECG
TREATMENT-
Stopping the Phenytoin .
DIAGNOSIS-
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
Gum hyperplasia, ataxia due to prolonged usage of Phenytoin are suggestive of chronic phenytoin toxicity.
DISCUSSION -
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