CASE 3: A 61 year old man with seizures and altered sensorium.

A 61 year old man with seizures and altered sensorium.

Hi, I am P. Shreya Reddy, 3rd semester medical student.This is an online elog book to discuss our patient's health data after taking his/her consent.This also reflects my patient centered online learning portfolio.

Case Scenario
A 61 year old man came to hospital on 20th August due to seizures and altered sensorium.

Chief complaints
- seizures
- altered sensorium for 2 hours
- 1 episode of vomiting 
- brief loss of consciousness

History of present illness
- patient was apparently asymptomatic 3 years ago, then he developed weakness, for which he was diagnosed with hypertension and was advised to take tablet TELMA - AM, but he took the medication irregularly.

- he was fine till 20th August when he had dinner and took 2 doses of hypertension medication following which he suddenly developed seizures, altered sensorium for 2 hours and brief loss of consciousness.

- he previously came to the OPD with complaint of a lesion on his right lower limb for which he was diagnosed with cellulitis secondary to stasis eczema and the blood investigations done at that time, it was noticed that he was hyperglycemic. He was then prescribed OHA's to bring down his blood sugar levels, due to which he became hypoglycemic now.
- no history of chest pain, palpitations, and edema.
History of past illness
- he is a known case of hypertension on medication since 3 years.

- not a known case of asthma, CAD, epilepsy, tuberculosis and cancer.

Drug History
- irregular hypertension medicine tab TELMA-AM for past 3 years.

Personal History
- married
- normal appetite 
- mixed diet
- regular bowels
- normal micturition 
- no known allergies 
- occasional alcohol consumption 

Family History
No known cases of: 
- diabetes mellitus 
- hypertension 
- heart disease
- stroke
- cancer
- tuberculosis 
- asthma
- other hereditary diseases

Physical examination
- no pallor
- no icterus
- no cyanosis 
- no clubbing of fingers
- no lymphadenopathy 
- no edema of feet
- no malnutrition 
- no dehydration 

Vitals
Pulse rate: 62 bpm
Respiratory rate: 14 bpm
BP: 110/70 mm Hg
SPO2: 100% at RA
GRBS: 39 mg/dl
Temperature: afebrile

Systemic examination

Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs

Respiratory System
- no dyspnea
- no wheezing 
- trachea position: central
- breath sounds: vesicular

Abdomen
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable 
- spleen: not palpable
- no bowel sounds
- genitals: normal

Central Nervous System
- conscious 
- normal speech
- no neck stiffness
- no Kernig's sign
- cranial nerves: normal
- sensory : normal
- motor: normal

Investigations

ECG:
DOPPLER:
BACTERIAL CULTURE:
GRBS:
MEDICATION:

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