45 years old male with seizures one week back
an episode of seizures 1 week back and he had bleeding from mouth
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 20 years ago after which he started consuming alcohol ,initially he started consuming toddy when he was young then he started consuming alcohol with his friends at his work 3-6 units weekly once on Sunday.This continued for 7years back.He started consuming alcohol excess due to family problems.he had 3 years back ah/o of 3episodes of seizures each episode precedes consumption of alcohol is present.he decided that alcohol might be the reason and went to a local doctor who told the same reason for which he decided to stop consuming alcohol which he did.he was abstinent for one year.Again he started consuming alcohol duo to family problems. One week back then he developed 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(brandy) 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
- Patient is conscious, coherent and non cooperative
- he is well oriented to time, place, person.
- moderately built and moderately nourished.
- Pallor- Absent
- Icterus- Absent
- cyanosis- Absent
- Clubbing-Absent
- Lymphadenopathy- Absent
- Pedal edema- Absent VITALS:
- Temperature - 98.7 F
- Pulse rate - 72 beats per min
- respiratory rate - 20 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
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 UL LL LL
BULK Normal Normal Normal Normal
TONE Normal Normal Normal Normal
POWER 5/5 5/5 5/5 5/5
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
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