GM case 3
GM CASE 3
March 28/03/2023
GM case 3
Case scenario.....
Hi, this is M Sharath chand, 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:
He is an utensil maker
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:
Dysponoea: no
Wheeze: no
ABDOMEN:
Tenderness : no
Palpable mass: no
Liver : not palpable
Spleen: not palpable
CENTRAL NERVOUS SYSTEM:
Level of consciousness: drowsy
Speech: normal
CLINICAL INVESTIGATION
PROVISIONAL DIAGNOSIS:
Alcohol withdrawal seizures
TREATMENT:
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?
For how long does he has to continue his treatment?
M Sharath chand
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