SUPRIYA GAGIREDDY 42

Hi,I am supriya 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 resident of miryalaguda 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 



HISTORY OF 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 craving for alcohol increased. 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 6months back and 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 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 .



PAST HISTORY
N/k/c/o DM,TB,Bronchial asthma, CAD. 
Known case of epilepsy since 10yrs and on medication. Tab. Levipil 500mg




PERSONAL HISTORY
Married
Mixed diet
Occupation:
Bowels :regular
Appetite:normal
Micturition:normal
No allergies
Alcohol 90ml/day  since 25years and gutka

FAMILY HISTORY
No significant family history but paralysis is seen in his father and brother. 

TREATMENT HISTORY
On medication since 10yrs levipil 500mg


GENERAL EXAMINATION
patient is concious coherent co - ooperative and well oriented to place and time

He is moderately built and nourished

PHYSICAL EXAMINATION
No Sign of pallor, Icterus,cyanosis,clubbing,Lymphadenopathy


VITALS
Temperature:98.6°c

PR -68bpm RR:20cpm

Bp - 160/80mmhg

GRBS- 201mg/dl

Spo2 - 94 % 

SYSTEMIC EXAMINATION



CARDIOVASCULAR SYSTEM
SI and S2 Heard

No murmurs


RESPIRATORY SYSTEM
BAE+

per abdomen: soft and nontender 

Non palpable no organomegaly


PER ABDOMEN
 NAD


CENTRAL NERVOUS SYSTEM
Speech -incoherent
Drowsy 1arousable


INVESTIGATIONS



PROVISIONAL DIAGNOSIS
Status epilepticus


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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