General medicine Case 6

CASE scenario....

Hi, I am D.Rajashri, 3rd BDS student. This is an online elog book to discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio.

                 CASE HISTORY

Patient Details
A 70 years old female, resident of chityala presented with
Chief complaint
*Giddiness since one week
*Fainted 3 times since one week
*Deviation of mouth since 1 day
*Slurring of speech since 1 day
History of present illness
Patient was apparantly asymptomatic one week ago then there was sudden onset of giddiness,giddiness more on position change,history of fall 3 episodes since one week even after intake of food, external injury and suturing done outside,altered sensorium and irritable behaviour, deviation of angle of mouth and slurring of speech since 1 day
History of past illness
Not a known case of hypertension, diabetes,fever,cought, tuberculosis, vomiting, shortness of breath, abdominal pain,loose stools
Known case of seizures 
Personal history
Diet- mixed diet
Sleep-adequate
Appetite- normal
Mituration-normal
Bowel-regular
Allergies -no
Family history
No history of similar complaints in the family
General examination
Patient was unconscious
Patient was normally built and normally nourished 
Pallor-present
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Vitals
Temperature:96.8
Blood pressure:140/60
Pulse rate:82
Respiratory rate:18
Provisional diagnosis
Acute Cerebrovascular Attack






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