A 45 year old male, came to opd with complaints of seizures.

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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 a case of 45 year old male resident of chityala, farmer by occupation came to general medicine OPD with chief complaints of:

CHIEF COMPLAINTS 

an episode of seizures on Monday(28/11/2022), 1week back and had bleeding from mouth during seizures.

 HISTORY  OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 1 week back, then he had an episode of seizures when he was at his farm doing work on monday. Seizures lasted for 5min. then he was taken to local RMP for the treatment, where he had given a tablet for it and the seizures subsided. then he came to opd on wednesday and he was adviced to get investigations done. but he refused due to lack of money and went back home. again he came back to the opd for the treatment on 3/12/2022.

PAST HISTORY 

He had a past history of episodes of seizures, since 2 years.

he had 3 episodes of seizures with six months interval between the episodes.

Not a k/c/o HTN, DM, ASTHMA, EPILEPSY, THYROID DISEASE, CAD.

PERSONAL HISTORY

Appetite decreased,

Sleep adequate,

bowel movements regular,

bladder regular, 

addictions: he consumes alcohol every one week from 25 years amount  90+45 ml

                  he had consumed alcohol the day before he had seizers  180ml 

 smoker (  kini  ) :  every day since 7 years  ( 1 packet =2 days ).

Daily Routine:

he wakes up daily early in the morning at 4:00 am. Then he gets ready to go to work at local cows shed for cleaning and motor maintaining duty. Then he come home by 7:30 am, eats breakfast usually he eats rice. Then he goes to work at his farm agriculture land, before going into work he usually consume alcohol 90ml and eats lunch at 1:00pm usually rice. Then at Evng he comes to home by 5:30 to 6:00 pm and goes out with friends where he consumes alcohol again 45ml. Then he eats dinner at home, sometimes he has decreased appetite after consuming alcohol. 

Family History :

 No significant family history.

ALLERGIC HISTORY:

• no known allergies to food or medication.
• no history of allergy to drugs. 

GENERAL PHYSICAL EXAMINATION:

• Patient is conscious, coherent and non cooperative
• he is well oriented to time, place, person.
• examined in a well lit area
• moderately built and moderately nourished.

• Pallor- Absent
• Icterus- Absent
• cyanosis- Absent
• Clubbing-Absent
• Lymphadenopathy- Absent
• Pedal edema- Present
• Skin is dry.

VITALS:

• Temperature - 98.7  F
• Pulse rate - 73 beats per min
• respiratory rate - 29 breaths per min
• Blood Pressure -140/80 mm of Hg.

SYSTEMIC EXAMINTION:

    CNS :

HIGHER MENTAL FUNCTIONS:

Right Handed person, he studied upto 10th standard.

Conscious, oriented to time place and person.

MMSE 26/30.

speech : normal

Behavior : normal 

Memory : Intact.

Intelligence : Normal

Lobar Functions : Normal.

No hallucinations or delusions.

CRANIAL NERVE EXAMINATION:

1st   : Normal

2nd  :  visual field is normal

           visual acuity is normal

            colour vision normal

            fundal glow present.

3rd,4th,6th  :  pupillary reflexes present.

                      EOM full range of motion present

                      gaze evoked Nystagmus present.

5th             :  sensory intact

                      motor intact

7th             :  normal

8th             :  No abnormality noted.

9th,10th     : palatal movements present and equal.

11th,12th   : normal.

MOTOR EXAMINATION:                     Right                                           Left

                                           UL                            LL                      UL                    LL

   BULK                         Normal                    Normal                 Normal          Normal

   TONE                         Normal                   Normal               Normal           Normal 

   POWER                       5/5                          5/5                         5/5                 5/5 

DEEP TENDON REFLEXES:

   BICEPS                        2+                                2+                         2 +                      2+

   TRICEPS                      2+                                2+                         2+                       2+

   KNEE                            2+                               2+                         2 +                      2+

    GAIT: normal gait 

   

RESPIRATORY SYSTEM- 

Patient examined in sitting position

Inspection:-

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position

Palpation:-

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

Cricosternal distance is 3finger breadths. 

Percussion:- all areas are resonant

 Auscultation:-  Normal vesicular Breath sounds (NVBS) 

CVS

 

 S1, S2 heard, no murmurs, 

apex beat  in 5 th ICS, MCL

abdominal examination :\

Abdomen is soft and non tender

No organomegaly

No shifting dullness

No fluid thrill

LAB INVESTIGATIONS:

On 3dec  2022 

                                     

Ultrasound report:

on 4/12/2022 

                                                

Provisional diagnosis:- 

         alchol induced seizures with grade 1 fatty liver.

   

TREATMENT  :

 TAB levipril 500mg BD 

 INJ thiamine  200mg in 100ml NS BD 

INJ pan 40mgOD

INJ ZOFER IV/SOS

Follow up: TREATMENT (4/12/2022, 4:45pm)

TAB lorazepam 2mg DO/SOS

TAB Baclofen  20mg BD for 4 days 

Nicotine gums/SOS