16 years old female suffering from seizure

This is an E-log to discuss case scenario of a patient with their guardian's help.

I have been given this case to solve in an attempt to understand topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, clinical findings, investigation and come up with diagnosis and treatment plan.

A 16 years old female resident of Deverakonda, Telengana came to OPD on 13 February 2023.
 CHIEF COMPLIANT:
Involuntary movement of both upper and lower limbs since morning and fever since 5 days.

HISTORY OF PRESENT ILLNESS:
 patient came home 3 days ago with complains of fever and generalised body pains, from hostel for which she has taken to RMP doctor where she was prescribed some medication.after taking that medication her fever subsided but OD observed.
Generalised body swelling at around 7pm patient went to pass stool after passing which she started having giddiness . shortness in breath and fearfulness for which she was taken to RMP.she was given injection after which she faint and didn't woke up till 3 am .
Patient woke up around 3 am and complaining about shortness of breath again after which she started having involuntary movement of hands and legs and uprolling of eyes and forthing of saliva . After which multiples seizure episode  reported by OD. She was brought to KIMS narketpally where  again she had seizure like activity.
 PAST HISTORY:
Hypertension  condition was noticed .
Diabetes,asthma,TB are not seen.
No head injury,no palpitation
FAMILY HISTORY:
Not significant
PERSONAL HISTORY:
 Diet : mixed
Appetite: decrease in appetite
Bowel and bladder: normal
Sleep : inadequate
Addiction: none
GENERAL EXAMINATION:
 Patient is conscious, coherent, cooperative,well oriented to time and place .
VITALS:
pluse rate : 106 bpm/min
BP: 140/100mmhg
RR: 16/min
pallor : absent
Cynosis : absent
SYSTEMIC EXAMINATIONS:
CVS: cardiac sounds S1 ,S2 are heard
Respiratory: dyspnoea not seen 
                       Wheeze not seen
                       Position of trachea : central
Abdomen: 
Shape of abdomen: scaphoid
Tenderness : not seen
Liver : not palpable
Spleen : not palpable 







   

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