36 year old male with involuntary movement of b/l upper and lower limbs.

August 24, 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

Case-

A 36 year old male patient came to the casualty at 3 in the morning with seizures.

History of presenting illness-

The patient was apparently asymptomatic yesterday night. He had a high intake of fruits and 180ml of wine during dinner. In the early hours the next day he developed seizures which was sudden in onset and was aware of it’s occurring. He had 4 episodes, first episode lasting for 3-4 minutes.There was stiffness mouth deviation to the left side, involuntary movements for 20-30 seconds first starting on left side and the becoming generalised, froathing at mouth and tongue biting.The other episodes followed within 5 minutes of each other and lasting for 2-3 minutes each. In between each episode he showed altered senses and was aware of his surroundings.

History of altered perception, loss of balance, exertional weakness.

No history of behavioural changes, loss of consciousness, impaired bowel and bladder, loss of limb control.