45 year old male came with a complaint 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 hailing from chityala farmer by occupation came to general medicine OPD with chief complaints of
CHIEF COMPLAINTS
an episode of seizures 1 week back and he had bleeding from mouth
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 week back, then he has an episode seizures while he was doing his work on monday .then he went to the RMP for the treatment he had given a tablet for it and the seizures subsided .he came to the opd on wednesday and he was advised for the investigation .
he refused due to lack of money and went back home
he came back again to the opd for the treatment on 3/12/2022
PAST HISTORY
He had a past history of episode of seizures 2 year back
he had three epi of in six months interval
Not a k/c/o HTN, DM, CAD, ASTHMA, EPILEPSY, THYROID DISEASE.
Personal history:
Sleep: adequate
appetite: decreased,
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 27 years ( 1 packet =2 days )
Family History :
No significant family history.
ALLERGIC HISTORY:
- no known allergies to food or medication
- no history of allergy to drugs
- 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- Absent
- Skin is dry.
- Temperature - 98.7 F
- Pulse rate - 73 beats per min
- respiratory rate - 29 breaths per min
- Blood Pressure -140/80 mm of Hg.
SYSTEMIC EXAMINATION :
CNS :
HIGHER MENTAL FUNCTIONS:
Right Handed person, studied upto 7 th standard.
Conscious, oriented to time place and person.
speech : normal
Behavior : normal
Memory : Intact.
Intelligence : Normal
Lobar Functions : Normal.
No hallucinations or delusions.
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
visual field 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
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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
.
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
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