A 45 yr old male patient with GTCS

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

A 45 old male patient presented to the opd with the cheif complaint of fits .

HISTORY OF PRESENT ILLNESS -

-patient was apparently asymptomatic until midnight 1Am.Then he developed with seizures around 1 to 2 am.
-Each episode lasts for 2 to 3 min associated with tongue bite and uprolling of eye balls .
-Patient had a total of 3 episodes with postictal confusion for 5 to 10 mins and vomiting after each episode.
-no history of fever and headache .
-history of left lower limb swelling on and off associated with pain since 1 month .
-no other complaints

HISTORY OF PAST ILLNESS .

-patient had a history of similar complaints 2years back.
-patient is a known case of diabetes mellitus since 2 years and on medication with
GLIMY-M1-OD.

PERSONAL HISTORY-

Diet-mixed 
His bowel and bladder movements are normal.
Patient is chronic alocoholic since 20 years and started taking more amount of alcohol since last 2 years .
He had been binge drinking from past 4 days and last drink was taken yesterday night.

FAMILY HISTORY-

No history of similar complaints in the family .

TREATMENT HISTORY-

no history of drug allergies
No treatment taken for present illness 

GENERAL EXAMINATION-

patient is conscious, coherent and cooperative.
-no pallor
-no icterus 
-no clubbing 
-no cyanosis 
-no generalized lymphadenopathy
-no bipedal edema .
VITALS:-
temperature-97.4 degree F.
Pulse rate -80 bpm.
Respiratory rate -20 cycles /min .
B.p-110/90.
SpO2-98%.

SYSTEMIC EXAMINATION-

CVS-
Insepction -chest wall is bilaterally symmetrical.
-no precordial bulge .
-no visible pulsations ,engorged viens ,scars sinuses .
Palpation -JVP is normal 
Auscultation-S1 and S2 are heard 

RESPIRATORY SYSTEM -

-postion of trachea is central .
-bilateral air entry is normal .
-normal vesicular breathe sounds heard .

PER ABDOMEN-

-abdomen is non-tender and soft .

CNS-

Patient is conscious,speech is normal .

PROVISONAL DIAGNOSIS-

GTCS secondary to alcohol intoxication.
Alcohol and tobacco dependence syndrome .
K/c/o type 2 diabetes mellitus .

INVESTIGATIONS-

USG DOPPLER LEFT LL :-chronic venous thrombosis with minimal recanalisation .
HB-15gm/dl.
TLC-11500.cells /cumm.
PLT-2.54lakhs.
RBS-99mg/dl.


FINAL DIAGNOSIS -

GTCS due to alcohol intoxication.

TREATMENT-

Inj LEVIPIL-1 GM IV/STAT --F/B-500MG IV/BD.
Inj THIAMINE 1 AMP 1N 100ML NS IV/TID.
Inj OPTINEURON 1 AMP 1N 100ML NS IV/OD.
Inj PAN 40 MG IV/TID.
Inj ZOFER 4MG IV /TID.
TAB LORAZ 2MG TID .
NICOTEX GUMS 2MG SOS .
W/F SEIZURE ACTIVITY .
GRBS MONITORING 4th hourly.
BP/PR/TEMP/SPO2 MONITORING .









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