This document contains a case presentation for a patient, including their demographics, chief complaint, history of present illness, review of systems, past medical history, family and social history, vital signs, and physical examination findings. The conclusion section is blank, indicating an assessment is still needed.

1. Case
Presentation
Student:
Department:

2. Name:
Age: Sex:
Occupation:
Address:
Marital status:
Religion:
Date of admission:
Date of examination:
Demographics

3. Chief complaint
• History of present illness

4. Review of systems
• General:
• Gastrointestinal:
• Respiratory:
• Cardiovascular:
• Urinary:
• Genital:
• Neurological:
• Musculoskeletal:
• Skin:

5. Past history
• Past Medical Hx.
• Past Surgical Hx.
• Hx. of Drug & Allergy
• Vaccination Hx.:

6. • Family history
• Social history

7. Physical examination
Vital signs
Heart rate: bpm
Respiratory rate: cycle/min
Blood pressure: / mmHg
Temperature: o
C ( site )
SpO2: %

8. General Examination:

9. Proper Examination:

10. Conclusion:

11. Thank you