GM CASES STUDY
Roll no .06
Below is an elog describing patient centered data approach and discussion regarding patient deidentified health data.
Patient was apparently asymptomatic 1 week then he had a complaint of abnormal jerk movements of both upper and lower limbs which are of 3 to 4 episodes of duration 5 mins.He also had a complaint of post ictal confusion of duration 20-30 mins and also complaint of tongue bite.
Then he had a complaint of chest pain on the left side since 3 days ,the pain is not radiating.
No h/o cough,fever,SOB,headache,,blurring
HISTORY OF PAST ILLNESS:
N/K/c/o:DM,HTN,Asthama,TB,Epilepsy.
H/o of TURP surgery for BPH.
FAMILY HISTORY:
No significant family history
PERSONAL HISTORY:
- Married
- Appetite is normal
- Mixed diet
- Bowels regular
- Normal micturation
- No known allergies
- Alcohol intake is present
- Known smoker
- No other habits or addictions present
GENERAL EXAMINATION
Patient is conscious, coherent
Absence of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal edema.
VITALS
1.Temperature:Afebrile
2.Pulse:75/min
3.Respiratory Rate:22
4.BP:120/80mm/hg
5.SPO2:85
6.GRBS:126mg%
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSTEM:
- S1 and S2 heard
- No thrills and murmurs
RESPIRATORY SYSTEM:
- Normal vesicular breath sounds
- Position of trachea is central
- Dyspnea is absent
- No wheeze
EXAMINATION OF ABDOMEN:
- Shape- scaphoid
- No tenderness
- No palpable pass
- Normal hernial orifices
- No free fluid
- No Bruits
- Liver is not palpable
- spleen is not palpable
- Bowel sounds heard
CENTRAL NERVOUS SYSTEM:
- Patient is conscious
- Speech is normal
- No focal neurological defect
- All reflexes were present
- Absence of cerebral signs
INVESTIGATION :
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