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

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- Absent

• 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 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 

 

                                                          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
                    . 
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   

                                     

on 4/12/2022 

                                                

Provisional diagnosis:- 

           alcholic withdrawl seizers with grade 1 fatty liver 

   

TREATMENT  :

  TAB levipril 500mg BD 

  INJ thiamine  200mg in 100ml NS/BD 

  INJ pan 40mg OD

  INJ ZOFER IV/SOS