A 80 year old male with Giddiness

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Hi, This is Vijaya Ratna,5th semester medical student .This Elog depicts the patient centered approach to learning. This is an online eLogbook recorded to discuss and comprehend our patient's deidentified health data shared, after taking his/her/guardian's signed informed consent.

A 80 year old male toddy climber by occupation resident of chityal came to casualty with chief complaints of involuntary movements of 1 episode associated with frothing from mouth lasting for 1 min with no regain of consciousness 
Giddiness 
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic till 2 years ago.He had paralysis 2 years ago and 1st episode of seizures with froth from mouth and loss of consciousness.1 year ago he had 2nd episode of seizure with involuntary micturition then he developed giddiness while walking and decreased vision due to this he is not being able to read and also can't differentiate the money notes.

Patient was a toddy climber till 8 years ago. But then he couldn't climb anymore due to his joint pains,giddiness and stopped working. He was a Toddy drinker back then.From 8 years he has been collecting pulses and selling them in the market. He also drinks whiskey (1 quarter) frequently and smokes beedi (1 packet) everyday. Has not been drinking and smoking since 6 months.

PAST HISTORY
H/o Hypertension since 2 years.
Not a known case of DM,TB ,CAD.

PERSONAL HISTORY
Occupation - Toddy climber
Appetite - normal
Diet - Mixed
Regular bowel and bladder movements 
Micturition - Normal
He has no known Allergies
Addictions
Alcohol- Regular
Tobacco - Smoking since 20 years but stopped 6 months back.

TREATMENT HISTORY
On Tab Telmisartan 
     Tab Hydrochlorothiazide medication for Hypertension since 2 years.

FAMILY HISTORY 
No family history

GENERAL EXAMINATION
Patient was conscious, coherent, cooperative, well oriented to time, place, person and examined in a well lit room.
VITALS
Temperature - 98.6F
Pulse rate - 90/min
Respiratory rate - 18/min
Blood pressure - 240/140mmHg
SpO2 - 98%
GRBS - 84mg/dl

PHYSICAL EXAMINATION
Pallor - Absent
Icterus - Absent
Clubbing - Absent
Cynosis - Absent
Lymphadenopathy - Absent
Edema of feet - Absent
Dehydration - No

SYSTEMIC EXAMINATION 
CARDIOVASCULAR SYSTEM
Thrills - No
Cardiac sounds - S1 & S2 heard
Cardiac murmurs - No

RESPIRATORY SYSTEM
Dyspnea - absent
Wheeze - absent 
Position of trachea -central
Vesicular Breath sounds - Normal

PER ABDOMEN
INSPECTION
Scaphoid shaped abdomen 
Umbilicus inwards
Movements with respiration- normal
Visible pulsations - No
Engorged veins - No
PALPATION
No Tenderness in any quadrants of abdomen,Liver and spleen.
Liver and spleen - not palpable
PERCUSSION
Dullness of abdomen - No
AUSCULTATION
No Bowel sounds

CNS 
Level of consciousness - stuporous
Speech - normal
Neck stiffness - No
Kernig's sign - No

INVESTIGATIONS
13/07/2022
USG
ECG
HEMOGRAM
ESR
ABG
RANDOM BLOOD SUGAR
BLOOD UREA
LIVER FUNCTION TEST
SERUM CALCIUM
SERUM CREATININE
SERUM ELECTROLYTES
SERUM MAGNESIUM
14/07/2022
MRI BRAIN
SERUM MAGNESIUM
2D ECHO
ECG
15/07/2022
LIPID PROFILE
SERUM MAGNESIUM
PROVISIONAL DIAGNOSIS
SEIZURES 

TREATMENT
Inj.LEVIPIL 500mg IV in 100 ml NS IV/BD
Inj.Loraz 2cc IV/SDS
T.Telma 40/0.5mg PO OD
Watch for seizure activity
T.Ecospirin 75mg PO OD
T.Atorva 40 mg PO

14/7/2022
Inj.Levipil 500mg IV in 100ml
Inj.Loraz 2cc IV/SDS
T.Telma H 40/0.5mg PO/OD
T.Ecospirin 75mg PO/OD
T.Atorvas 40mg PO/HS
W/f seizure activity
15/7/2022
Tab.Levipil 500mg PO/BD
T.Telma H 40/0.5mg PO/OD
T.Ecospirin 75mg PO/OD
T.Atorvas 40mg PO/HS
W/f seizure activity
Syp.Potklor 10ml + 1 glass water
T.Ultracet 1/2
16/7/2022
Tab.Levipil 500mg PO/BD
T.Telma H 40/0.5mg PO/OD
T.Ecospirin 75mg PO/OD
T.Atorvas 40mg PO/HS
T.Ultracet 1/2 BD
T.Neurobion forte PO/OD
17/7/2022
Tab.Levipil 500mg PO/BD
T.Telma H 40/0.5mg PO/OD
T.Ecospirin 75mg PO/OD
T.Atorvas 40mg PO/HS
T.Ultracet 1/2 BD
T.Neurobion forte PO/OD
18/7/2022
Tab.Levipil 500mg PO/BD
T.Telma H 40/0.5mg PO/OD
T.Ecospirin 75mg PO/OD
T.Atorvas 40mg PO/HS
T.Ultracet 1/2 BD
T.Neurobion forte PO/OD




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