GM case - 4

March 6th, 2023
Case scenario.....
Hi, This is Swarna Kurma, IIIrd year BDS. This is an online eblog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

 CASESHEET :A 42 year old woman has come to hospital with complaint of Fever, involuntary moments


CHEIF COMPLAINTS: Fever, involuntary movements.

HISTORY OF PRESENT ILLNESS:
(i)The  Patient  had symptoms of cold,cough  10 days ago
(ii)Then she was affected by fever
     FEVER : Low grade intermittent diurtional           variation at night time 
(iii)Chills at night
(iv) Body pains and headache during night
(v) Vomitings : Food particles
(vi) Stools : Loose stools ( watery) since 4 days
(vii) Seizures: 5 episodes of partial seizures
 
HISTORY OF PAST ILLNESS:
Gall bladder was operated six years ago
Asthma : No Asthma
Tuberculosis : No tuberculosis
CAD : No CAD
CVA : No CVA
BP : High BP
Thyroid : Hypothyroidism 


DRUG HISTORY:
Amlodipine & Atenolol tablets IP ( irregular usage from 3 months


PERSONAL HISTORY: 
Diet : Mixed
Appetite : loss of Appetite since 1week
Bowel : Loose stools before, recently recovered
Bladder movements : Normal
Addictions : No addictions
Known Allergies : nil

FAMILY HISTORY: 
Her Husband is diabetic since 9 yrs

GENERAL EXAMINATION:
Patient is Conscious , Coherent and Co-operative 
Built : Obese
Nourishment : nourished normally 
Pallor : No 
Icterus : No
Cyanosis : No
Clubbing : No
Lymphadenopathy : No
Edema : pedaledema previously present not now



VITALS:
Temperature: 104°f ( febrile on touch)
Pulse: 92 beats per minute ( bpm)
Respiratory rate: 16 cycles per minute ( cpm)
Blood pressure: 130 /90mm Hg
SPO2: 95%
GRBS : 211mg %


PROVISIONAL DIAGNOSIS :
The patient was diagnosed with "GTCS SECONDARY TO ACUTE GASTRO ENTRITIES"


Question:
1. What treatment has to be given to patient?



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