GENERAL MEDICINE ASSESSMENT
I am P. Sri Chandana Roll. No: 98 Below is an E-log describing patient centered data approach and discussion regarding patient de- identified health data this e log is made under the guidance of Dr madhumita (intern) CASE HISTORY: 64 yr old male patient came to casuality CHIEF COMPLAINTS: drowsiness Confusion in the afternoon after he came from work HISTORY OF PRESENT ILLNESS: drowsiness HISTORY OF PAST ILLNESS: no history of fall No history of seizure like activity,LOC No history of focal signs of weakness History of similar complaints in the past One episode 6 months ago One episode 1yr back N/k/c diabetes mellitus, hypertension, tb ,asthma ,epilepsy ,CAD PERSONAL HISTORY: Diet- mixed Appetite- normal Sleep- adequate Bowel and bladder movements- regular Addictions: alcoholic since 7 yrs, consumes 180ml per day GENERAL EXAMINATION: Patient is drowsy Vitals- PR=96bpm, RR= 16cpm Temp= 96F BP= 140/90 GRBS= 116 mg/dl. No signs of p