Loss of consciousness and Palpitations (55 Year old woman) GM - CASE 7
22nd August 2022
CASE STUDY 5
Hello, I am Saloni .S. Gangotri , a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.
CASE SHEET:
CHIEF COMPLAINTS:
c/o
- loss of consciousness since 30 mins.
- palpitations present.
- no fever
- no pain
- no sweating
HISTORY OF PRESENT ILLNESS:
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ASSOCIATED DISEASES:
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PAST HISTORY:
h/o
K/C/O DM since 2 years (on glibenclamide 2mg OD)
K/C/O HTN since 2 years.
No TB, Epilepsy, CAD.
PERSONAL HISTORY:
Regular Bowel movements.
Has normal micturition with no burning sensation.
Has no known allergies.
FAMILY HISTORY:
Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancers.
DRUG HISTORY:
GENERAL EXAMINATION:
-No palor
-No cyanosis
-No lymphadenopathy
-Icterus present
-No edema of feet
-No clubbing of fingers
-Temp - normal
-GRBS - 34
VITALS:
Temperature: Afebrile
Pulse: 60 beats per minute
Respiratory rate: — cycles per minute
Blood pressure: 160/90 mm of Hg
SPO²: 98
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes
Abdomen:
Shape : Scaphoid
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious and Alert
Speech: Normal
INVESTIGATIONS:
Biochemical investigations:
PATHOLOGY REPORT:
ECG:
2D ECHO REPORT:
ULTRASOUND REPORT:
PROVISIONAL DIAGNOSIS :
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