CASE 2

Hi, I am S.Siddharth, 3rd semester medical student. This is our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. This eblog also reflects my patient centered online learning portfolio.

CHIEF COMPLAINT

82 year old male patient , resident of muthkur came to opd with a chief complaint of fever since 5 days and involuntary movements in upper and lower limbs.

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 2 days back. In the afternoon he developed a high grade fever followed by involuntary movements in all the limbs. Tongue biting and uprolling of eye were also there.
Was taken to hospital and medications were given.
But later that night he developed those symptoms again.
He had tongue biting, uprolling of eyes, involuntary micturition and Bowel movements with postictal confusion for around 5 minutes
There is no history of similar complaints in the past
Initially after regaining consciousness he couldn't recognize the attendees but he got better after some time.

HISTORY OF PAST ILLNESS

No diabetes, No HTN, no asthma or any COPD

PERSONAL HISTORY 

Patient is farmer by occupation
married
Bowel movement is regular
Micturition normal
Non alcoholic

FAMILY HISTORY 

No significant family history 

PHYSICAL EXAMINATION

A.GENERAL EXAMINATION
Well built
Well nourished
pallor present


No icterus
No cyanosis
No pedal oedema
No clubbing of fingers
No lymphadenopathy
Mild dehydration

B.VITALS
Temperature
Pulse
Heart rate 
BP
INVESTIGATIONS

ECG - 05/09/2022







USG - 05/09/2022




Hemogram - 09/09/2022

2 D ECHO





TPR Chart

MRI BRAIN


CHEST X RAY :




MEDICATIONS

















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