60/F
C/O HEADACHE SINCE 6YRS, FRONTAL, RELIEVED ON TAKING PCM, NOT ASSOCIATED WITH NAUSEA, VOMITINGS, ASSOCIATED WITH FEVER AND DIZZINESS 
BURNING SENSATION, TINGLING, NUMBNESS IN BOTH LEGS AND HANDS SINCE 2 MONTHS
TWITCHING OF HANDS WITH CRAMPS
CHEST PAIN IN MID STERNUM WHICH RESOLVES AUTOMATICALLY 

BURPS +, HOARSENESS OF VOICE +, CONSTIPATION + POLYURIA +, POLYDYPSIA+, NOCTURIA +, SOB GRADE 2, DRY MOUTH +


K/C/O EPILEPSY SINCE 20YRS
H/O RT TIBIA FRACTURE SURGERY 
H/O RIGHT EYE SX 5 YRS AGO, LEFT EYE SX 3 YRS AGO
DM SINCE 8YRS, ON OHAS, CHANGED TO INSULIN SINCE 2 MONTHS
H/O TYPHOID FEVER 2 MONTHS AGO
H/O HYSTERECTOMY 8YRS AGO

PT IS C/C/C
NO PALOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA 
BP: 120/70 MMHG
PR: 86BPM
GRBS: 181MG/DL
CVS: S1,S2 HEARD
RS: BAE +, NVBS
P/A: SOFT, NT
CNS: HMF INTACT
SENSORY INTACT
PROPRIOCEPTION: RT AN LT SIDE ON BOTH UL AND LL IS 10/10
POWER IN B/L UL IS 5/5 AND LL IS 4+/5
TONE IN B/L UL AND LL IS NORMAL
GRAPHESTHESIA AND STEREOGNOSIS IS NORMAL B/L

HEADACHE UNDER EVALUATION
DM2 SINCE 8YRS

INJ MIXTARD S/C BD 10-10U
TAB PREGABA-M PO HS
TAB NAPROXEN PO OD
SYP CREMAFFIN 15ML PO HS

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