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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.
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
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
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