Gm case( 74 yr male)
74 yr old male with seizures
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I’ve 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.
Following is the view of my case :
Date of admission : 13/11/22
74 year old male , farmer by occupation came to the opd with
Chief complaints :
Of seizures and loss of consciousness AT 1:00 AM ON 13/11/22
History of present illness :
Patient was APPARENTLY ALRIGHT TILL YESTERDAY 1:00 am , then he SUDDENLY DEVELOPED INVOLUNTARY MOVEMENTS OF ALL 4 limbs associated with frothing, uprolling of eye balls and altered sensorium for which he was brought to the hospital . There were 4 such episodes since night which lasted for 3 to 4 minutes
No aggrevating or relieving factors
Past history:
K/c/o tuberculosis 4 years back used medications for 1 year
K/c/o diabetes from past 5 months
N/k/c/o htn,asthama, epilepsy, CAD,CVA
Family History:
Not Significant
Personal History:
Diet - mixed
Appetite - normal
sleep - adequate
Bowel and Bladder movements -regular
Addictions - 2 packs of beedi daily, regular toddy consumption from past 50 years
No known allergies
Drug history :
No significant drug history
General examination :
Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person at the time of examination.
He is well nourished and moderately bulit
Pallor - mild
Icterus - absent
Cyanosis - absent
Clubbing - absent
lymphadenopathy - absent
Pedal edema - absent
Vitals : on the day of admission
Pulse rate - 76 bpm
Respiratory rate - 16 cpm
Blood pressure - 130/90 mmHg
Temperature - afebrile
Systemic examination :
CVS : S1 and S2 heart sounds hear
NO murmurs and thrill
RESPIRATORY SYSTEM : Bilateral air entry present
position of trachea - central
Vesicular breathsounds heard
CNS :
▪︎NAD and HMF intact
ABDOMEN
Soft
Non tender
No palpable mass
Bowel sounds heard
NO organomegaly
CLINICAL IMAGES
PROVISIONAL DIAGNOSIS:
Generalized tonic clinical seizures under evaluation
TB 5 years back
Diabetes: 5 months back
INVESTIGATIONS
Hemogram
Post lunch blood sugar
Serum electrolytes and serum ionized calcium
Serum creatinine
Serum calcium
HBsAg
Lipid profile
Liver function test
HIV 1/2 rapid test
Complete urine examination
USG ABDOMEN
MRI brain
Chest x ray
Bacterial culture and sensitivity report
TREATMENT
1.Inj.LEVIPIL 500MG IV BD
2.INJ.OPTINEURON 1AMP IN 500ML NS IV OD
3.MONITOR VITALS AND INFORM SOS
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