Akshara kruthi 40
Hi,I am G.Akshara kruthi 5th sem medical student.This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual 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 reflects my patient centered online learning portfolia
45 yrs old male patient came to the causality with the chief complaints of
* Seizures on 15th July night which is continuous till 16 th July 6 Am with few intervals
* Right shoulder dislocation during the seziures
Present illness :
Patient was apparently asymptomatic 25 yrs back .Then he started drinking alcohol of 90ml /day and from 10 yrs his alochol consumption is increased where he got sleep disturbances without alochol and he also had a habit of eating gutka since 25 yrs used to eat 4-5 packs / day .
He had 1 St episode of seziures 12 yrs back and on medication and 2nd episode was 6 mnts back and used to come every month single episode then there were continuous episodes from 15 th July night with few intervals where his right hand shoulder got dislocated and went to nalgonda where they said to come on 16 th of mng but still seizures started at 3 Am of 16 th July to 6 Am and they came to Kims narketpally where the patient got stabilized .
History of past illness :
K/c/o epilepsy and was on medication Tab.levipil 500 mg
Not a k/c/o of DM ,HTN ,asthma ,CAD,TB .
Family history :
No significant family history of seizures but paralysis is seen in his father and brother.
Personal history
Married
Occupation : ironer
Appetite:normal
Non veg
Bowels:regular
Micturition:normal
No known Allergies
Addictions
Alcoholic 90 ml /day since 25 yrs
Gutka since 25 yrs
PHYSICAL EXAMINATION
A. GENERAL EXAMINATION
Patient was conscious, coherent, co- operative. Well oriented to time, place and person.
No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No edema
No malnutrition
No dehydration
VITALS
TEMPERATURE-98.6
BP-160/80mm of hg
PR :68 BPM, regular
GRBS : 201mg%
Spo2:94%
B. SYSTEMIC EXAMINATION
Patient was examined in a well lit room after taking the proper concern.
CARDIOVASCULAR SYSTEM
S1, S2 +ve.
No murmers
RESPIRATORY SYSTEM
BAE +ve
Normal vesicular breathe sounds heard
PER ABDOMEN
Soft ,no tenderness
Not palpable
CENTRAL NERVOUS SYSTEM
Conscious
Normal speech
No neck stiffness
No kernings sign
Cranial, motor, sensory systems :NAD
REFLEXES
Normal reflexes
Investigation :
Treatment :
Normal diet
Inj. Levipil 500mg
Inj. Thiamine 200mg
Inj. Monocef
Inj. Pan
Inj. Zofer
Inj. Loraz
Inj. Ultracet
Chlorhexididne +bethadine mouth wash
Tab chymerol forte
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