Case Study 5
October 18 ,2021
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October 18 , 2021
A 45 year old male presented to OPD for SOB and
burning sensation in the stomach.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 6 months back
and then developed SOB and burning sensation in the
stomach then he visited KIMS and got treatment and
then again he developed SOB , burning sensation in the
stomach with repeated burps and he got admitted in
the hospital 2 days back.
He has a history of seizures since childhood and due to
which he stays at home . The patient said that seizures
occur when he is cold and may occur at any time
randomly and he's taking phenytoin for seizures.
PAST HISTORY
No history of Diabetes mellitus and Hypertension.
No history of Asthma, Tuberculosis
PERSONAL HISTORY
Appetite - Normal
Bowel and bladder movement - Regular
Diet - Mixed
Sleep - Adequate
Habits - He consumes alcohol occasionally
No known allergies
FAMILY HISTORY
No significant family history
ON GENERAL EXAMINATION
She was conscious, coherent and cooperative
Temperature - 98.4 °F
Pulse rate - 108 bpm
Blood pressure - 110/70 mmHg
SpO2 -
Respiratory Rate -
No Pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal edema
No malnutrition
SYSTEMIC EXAMINATION
CVS:
S1 and S2 heard
No murmurs
RESPIRATORY SYSTEM:
Normal Vesicular breath sounds heard
Bronchial artery embolism
PER ABDOMEN:
Soft
Non tender
CNS:
Oriented to time , place and person
PROVISIONAL DIAGNOSIS
Seizures
REPORTS
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