117-gopi telaputla

 82 year old male patient with fever and seizures


September 11, 2022


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



CHIEF COMPLIANTS 

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


Mild pallor present




No icterus


No cyanosis


No pedal oedema


No clubbing of fingers


No lymphadenopathy


Mild dehydration



B.VITALS


Temperature - 99°F


Pulse - 70


Heart rate 


BP


INVESTIGATIONS


ECG - 05/09/2022




USG - 05/09/2022





Hemogram - 09/09/2022




TPR Chart





2D ECHO 







CHEST XRAY



MRI BRAIN




MEDICATIONS










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