CASE STUDY


By kundana kanumilli (3rd sem)

A 40 year old male came to casualty

CHIEF COMPLIANT

seizure activity

HISTORY OF PRESENT ILLNESS

The patient was apparently asymptomatic 5-6 months back when he had 5 episodes of seizure -Focal [right sided] with secondary generalization which is associated with involuntary micturition for which he was taken to a local hospital and got treated symptomatically

The patient was referred to one hospital for further treatment 
Patient was brought to casualty in a state of altered sensorium
GCS :E3 V4 M5
Patient has history of generalized weakness and body pains since 1 day
there are no other complaints
 
PAST HISTORY

No history of Diabetes mellitus
                        Hypertension
                        Coronary artery disease
                        Asthma
                        Tuberculosis
PERSONAL HISTORY

Married

Normal appetite

Regular bowels

Daily wage labourer

Habits: Alcohol from past 20 years 180ml/day
            
         Smoking Cigeratte from past 20 years 15/ per day 

FAMILY HISTORY

There is no specific family history

GENERAL EXAMINATION

Patient is drowsy,incoherent,co-operative and moderately built examined in well lightened room

NO Pallor 

NO Icterus

NO Cyanosis

NO Koilonychia

NO Lymphadenopathy

NO Edema

Temperature:100F

Pulse rate :96 /min

Spo2 at room air 99%

SYSTEMIC EXAMINATION

CVS

S1 and S2 heard there are no murmurs

RESPIRATORY SYSTEM

Normal vesicular breath sounds,
No wheeze , No dyspnea ,
 trachea is central

ABDOMEN

Shape of abdomen - Scaphoid

No tenderness 

No palpable mass, fluid , bruit

No palpable liver  , spleen

 P/R : no

CNS

Is Drowsy

Incoherent

Glasgow scale E3V4M5





REFLEXES


Right arm :slight increase in intensity

Left arm :slight increase in intensity

Both right and left knee : exaggerated reflex

Plantar reflex: unelicitable

INVESTIGATIONS

COMPLETE URINE  EXAMINATION


HEMOGRAM



Hemoglobin- 12.9 gm/dl
Total count -19000 cells/gm
Lymphocytes -13 % 
PCV -38.1vol %
RBC count -4.42 millions/cumm

ELECTROCARDIGRAM

TREATMENT

Iv Fluids-NS at 100ml/hr[continuos infusion]
Inj CEFTRIAXONE 1 gm IV
Inj LEVIPIL 500mg IV
Inj LORAZ 2cc IV

Inj THIAMINE 1 amp 100 ml NS  IV
Inj OPTINEURON 1 amp 100 ml NS IV
Tab DOLO 650 mg

PROVISIONAL DIAGNOSIS

FOCAL SEIZURE WITH SECONDARY GENERALIZATION 
ALTERED SENSORIUM UNDER EVALUATION
? Meningo encephalitis
?Septic encephalopathy

PLAN

CSF analysis

Comments

Post a Comment

Popular posts from this blog

Image
40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS    December 06, 2023   40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS  ** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required. Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified  health data shared, AFTER taking his/her/guardian's signed informed consent. Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs. This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to de
Read more

A 55 yr old male with lower back pain

Image
​ E-LOG GENERAL MEDICINE Hi, This is Kundana , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them Chief complaints:    Patient complains of shortness of breath , fever and lower back ache . shortness of breath since 10 days Lower back pain simce 10 days  History of present illness:   The patient is apparently asymptomatic one month ago , then he developed shortness of breath  shortness of breath: insidious onset , grade-2 (NYHA) , gradually progressive  History of orthopnea, PND, cough present No history of chest pain , cold  Decreased urine output since one month Thin stream , poor flow, increased frequency, hesitency sensations present, burning micturition present, but no pain during micturition Pain: at lower back , dull boring typ
Read more