GENERAL MEDICINE E-log

NAME: A Sanvith

ROLL NO: 09

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CHIEF COMPLAINT:

A 78yrs old male carpenter by occupation came to opd with chief complaints of 

Pain abdomen (left side)

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 week then he had a complaint of tonic 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,sudden onset,blurring of vision




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 :




















 


21/06/2022







PROVISIONAL DIAGNOSIS
Seizures
Pneumonia?

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