General medicine blog -5

A 61 year old man with seizures and altered sensorium.


Hi, I am Sainath Reddy, 3rd semester medical student.This is an online elog book to discuss our patient's health data after taking his/her consent.This also reflects my patient centered online learning portfolio.

Case Scenario
A 61 year old man came to hospital on 20th August due to seizures and altered sensorium.

Chief complaints
- seizures
- altered sensorium for 2 hours
- 1 episode of vomiting 
- brief loss of consciousness

History of present illness
- patient was apparently asymptomatic 3 years ago, then he developed weakness, for which he was diagnosed with hypertension and was advised to take tablet TELMA - AM, but he took the medication irregularly.

- he was fine till 20th August when he had dinner and took 2 doses of hypertension medication  following which he suddenly developed seizures, altered sensorium for 2 hours and brief loss of consciousness.

- he previously came to the OPD on 3rd August with complaint of a lesion on his right lower limb for which he was diagnosed with cellulitis secondary to stasis eczema and the blood investigations done at that time, it was noticed that he was hyperglycemic. He was then prescribed OHA's to bring down his blood sugar levels, due to which he became hypoglycemic now.


- no history of chest pain, palpitations, and edema.

History of past illness
- he is a known case of hypertension on medication since 3 years.

- not a known case of asthma, CAD, epilepsy, tuberculosis and cancer.

Drug History
- irregular hypertension medicine tab TELMA-AM for past 3 years.

Personal History
- married
- normal appetite 
- mixed diet
- regular bowels
- normal micturition 
- no known allergies 
- occasionally consumes alcohol 

Family History
- no diabetes mellitus 
- no hypertension 
- no heart disease
- no stroke
- no cancer
- no tuberculosis 
- no asthma
- no other hereditary diseases

Physical examination
- no pallor
- no icterus
- no cyanosis 
- no clubbing of fingers
- no lymphadenopathy 
- no edema of feet
- no malnutrition 
- no dehydration 

Vitals
Pulse rate: 62 bpm
Respiratory rate:  14 bpm
BP: 110/70 mm Hg
SPO2: 100% at RA
GRBS: 39 mg/dl
Temperature: afebrile

Systemic examination
Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs

Respiratory System
- no dyspnea
- no wheezing 
- trachea position: central
- breath sounds: vesicular

Abdomen
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable 
- spleen: not palpable
- no bowel sounds
- genitals: normal
- speculum examination : normal
- P/R examination : normal

Central Nervous System
- conscious 
- normal speech
- no neck stiffness
- no Kernig's sign
- cranial nerves: normal
- sensory : normal
- motor: normal

Investigations
Complete Blood Picture on 03/08/22

Complete Urine Examination on 03/08/22

Renal Function Test on 03/08/22

Liver Function Test on 03/08/22

Random Blood Sugar on 03/08/22

Erythrocyte Sedimentation Rate on 03/08/22

Fasting Blood Sugar on 04/08/22

Post Prandial Blood Sugar on 04/08/22

ECG on 20/08/22

Doppler test on 16/08/22

MRI of brain on 20/08/22

Bacterial culture and sensitivity on 18/08/22

Temperature chart

Medication Chart

GRBS Monitoring




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