Gm case-4

Case scenario.....

Hi, this is P.Minnu 3 rd BDS student. This is an online eblog book to discuss our patient's health data after taking his consent. This also reflects my patient centered online learning portfolio.

CASE SHEET:

A 60 year male who has been attacked with seizure.

 Chief Complaint:

Patient had seizure 4 days ago.

vomiting since 3 days .

HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic 5 days ago.

He had seizure 4 days ago.

The attack of seizure was with gap of 3 to 4 hours.

He had seizure like activity for 10 minutes.

During his seizure his four limbs were rigid. His eyes were uprolling

There was no involuntary micturition during his seizure.

Frothing from the mouth.

The patient murmurs during his sleep this started suddenly after his first seizure.

Vomiting contained food particles. 

The frequency was 2 to 3 times a day.

There was no blood tinged in vomit.

PAST HISTORY:

Pulmonary tuberculosis 10 years ago(used medication for 6 months)

Consumption of alcohol regularly (6 units aday)

Tobacco chewing one pack a day.

Diabetes: no

Hypertension: no

CAD: no

CVA : no

Epilespy: no

FAMILY HISTORY: no similar complaint.

PERSONAL HISTORY:
Marriage status: married

Appetite: normal

Diet: non- vegetarian

Sleep: normal

Bowel: regular

Allergy: no

Addiction:          Alcoholconsumption(regular) 

Tobacco chewing

VITALS:
Temperature: 100.2 degree Celsius

Pulse rate: 94per minute

Respiration rate  : 28 per minute

BP: 110/80mm/Hg

SPO2:  99%

GENERAL EXAMINATION;

Pallor: no

Icterus: no

Cyanosis: no

Clubbing: no

Lymphadenopathy: no

Oedema: no

SYSTHEMIC INVESTIGATION:

CARDIO VASCULAR SYSTEM:

Thrills: no

Murmurs: no

Cardiac sound : s1, s2 heard

RESPIRATORY SYSTEM:

Dyspnea: no

Wheeze: no

ABDOMEN:

Tenderness : no

Palpable mass: no

Liver : not palpable

Spleen: not palpable

CENTRAL NERVOUS SYSTEM:

Level of consciousness: drowsy

Speech: normal

PROVISIONAL DIAGNOSIS:

Alcohol withdrawal seizures

Questions from patient:

How long he need to take the medication?

Are there any other risk because of seizure?

Questions from myside

What is the reason for loss of appetite and how is it related to seizure?

Why is the patient murmurs all of sudden while he is asleep this started after his first seizure?