CASE HISTORY

 Chief complaint: 

A 45 yr old male from nalgonda was presented to opd with complaints of fever,vomiting and an episode of seziure

History of present illness:

Patient apprantely complaints of fever and chills

History of past illness:

Patient stopped working because of generalized weakness

Personal history:

Appetite-Normal

Diet- mixed 

Bowles- normal

Micturaition-normal

Habits- alcohol(weekly twice)

Family history:

No history of diabetes 

No history of hypertension 

No history of heart diseases 

No history of cancer 

No history  of TB

Drug history:

Patient is not allergic to any Known drug 

Systemic examination 

CVS:

No Thrills 

S1 S2 sounds heard 

No cardiac murmurs 

Respiratory system 

Central portion of trachea 

No dysponea 

No wheezing 

CNS:

Level of consciousness-drowsy

Speech -slurred

Provisional diagnosis

Altered sensorium 2° to hyponatremia/alcohol with drawal

Investigations 

CBP



Serum Electrolytes 
Blood urea


Treatment 

 Inj.Pantop 40mg IV/OD

Inj.zofer 40mg IV/SOS

Inj.neomol 100ml

Inj.levipil 500mg/BD




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CASE HISTORY

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