GM CASE STUDY
Anvitha reddy
Roll no .06
Introduction
A 70 year old male resident of nalgonda daily wage worker ( ploughing of seed , cotton picking ) by occupation came to hospital with cheif complaints of left eye blurred vision.
Chief complaints:
Blurred vision ( left eye) since 1 year
Icthing all over the body since 2 months
History of presenting illness:
He was apparently asymptotic 15 years ago, then he developed deformities in lower limb ( resorption and clawing of all his toes) .
10 years back , he had loss of sensation ( pain , touch, temperature,vibration) of upper limb and lower limb.
Few years Back, he had right eye blurred vision for which he went through surgery which became normal
1 year back, he had left eye blurred vision
Since2-3 months ,itching all over the body and patches on the skin mainly seen on hands and hyerflexion of DIJ and hyperextension of. PIJ and also burning psensation on the skin
3days back, he had epilepsy in the hospital about 5mins .
History of past illness
No h/o DM,HTN,asthma, TB
He had right eye surgery
Personal history
Married
Diet : mixed
Normal bowel and bladder movements
Inadequate sleep
No addictions
Family history
No h/o TB,asthma,Dm,HTN and cardiovascular disease and epilepsy
General examination
No pallor
No icterus
No cyanosis
No lymphadenopathy
No pedal Edema
Muscle wasting is seen
Vitals:
Temp -afebrile
PR-70
BP-130/70
RR-14
GRBS-100%
System examination
CVS:
S1and S2 heard
No thrills
No murmurs
RESPIRATORY SYSTEM
No dyspnoea
No wheezing
Trachea is central
Breath sounds are vesicular
ABDOMEN:
No tenderness
No palpable abdominal mass
No splenomegaly
No hepatosplenomegaly
No bruits
Bowel sounds:NAD
CNS:
Conscious,coherent,cooperative
Speech is normal
SENSORY SYSTEM:
Loss of pain , touch,temperature,vibrations
Loss of sensation over forearm
MOTOR SYSTEM:
reflex lost
Investigation :
Comments
Post a Comment