Patient a 28 year old complains of involuntary movement of upper and lower limbs
History of present illness
Patient has a history of seizure on
21/12/2021
3 episodes around 3 am,7am,11am
Each episode lasting for 3-5 min
Seizure association with
Up rolling of eye ball
Brothing from the mouth
History of fever,weak back association with chills
Patient has no history of decreased urine output
Patient has no history of pedal edema
Patient urine has ,heamaturia, frothy urine
History of shortness of breath from 10 days
grade two- three
History of past illness
Patient is a known case of CKD who's on maintenance dailysis discontinued from 19/10/2021
Patient is a known case of hypertension
Diabetes-no
Hypertension present -.
Asthma absent
Tuberculosis absent
No . exposure to radiation
Personal history
Occupation works in cloth store
Unmarried
Appetite-lost
Diet-Mixed
Regular bowel and bladder
No allergy known
Alcohol usage occasional
Tobacco usage no
No addictions
Family history
No relevant family history
Physical examination
Weight 61kg
Height 5.6
Pallor present
No cyanosis
No lymphadenopathy
No malnutrition
Dehydration mild
Temperature 98.6 c
Pulse rate 88/min
Respiration rate 14/min
Bp 160/100mm hg
Spo2 98%
Grbs 130mg%
Systemic examination
Cvs
No thrills
No cardiac murmurs
Cardiac sounds s1,s2 heard
Respiratory system
Position of trachea central
Dyspnea present
No wheeze
Abdomen
No abdominal tenderness
No palpable mass seen
No free fliud
Liver not palpable
Spleen not palpable
Cns
Patient is conscious
Speech normal
Investigations
Treatment
Fluid restriction 2 litres/ day
Salt restriction 2grams/day
Tab lasine 40 mg Bd
Tab nicardia 10 mg bd
Tab orofer bd
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