General medicine case discussion

April 15, 2023

 General medicine case discussion

E LOG MEDICINE CASE

15/04/2023

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.

Name : Krishna Pranavi Y

Roll no : 61

Batch:2020

I''ve been given this case to solve in an attempt to understand the topic of "PATIENT CLINICAL DATA ANALYSIS" to develop my competency in reading and comprehending clinical data including history,clinical findings,investigations and comeup with Diagnosis and Treatment plan.


CASE DISCUSSION

Date of admission:12/04/2023

A 70 year old male came to opd who is a carpenter with 

CHIEF COMPLAINTS :
Weakness of the right upper limb

HISTORY OF PRESENTING ILLNESS:
Patient was asymptomatic one year ago.
Later he got sudden onset of paralysis of right upper limb and right lower limb associated with deviation of mouth to the right side, drooling of saliva and unconsciousness.
After one month of paralysis he was aware of his situation. He had 2 episodes of headache  in a week which is bilateral in the temporal region radiating to the occipital region . Tumbling sensation is present over the right upper limb and lower limb to the extent that he was not able to do his daily activities and is dependent on his wife and it subsided during sleep.  

PAST HISTORY:
A known case of hypertension since 10 years. 
No history of DM. 
No history of TB, epilepsy, bronchial asthma. 

PERSONAL HISTORY:
Appetite - Decreased 
Diet - Mixed diet 
Sleep - Irregular sleep due to headache. 
Bowel movements - Irregular 
Bladder movements - Normal 
Addictions - Alcohol 45 ml per day since 20 years and stopped one year back. BD 15 per day since 50 years. But decreased after paralysis. 

FAMILY HISTORY:
His mother has hypertension .

DRUG HISTORY:
He was using 
Amlodipine+ Atenolol 
Aspirin 
Donepizil

GENERAL EXAMINATION:
Conscious 
Coherent 
Poorly built 
Cooperative 
Moderately nourished  
Oriented to time, place and person. 
Pallor : Absent
Icterus : Absent 
Cyanosis : Absent 
Clubbing of fingers : Absent 
Lymphadenopathy : Absent 
Edema : Absent

SYSTEMIC EXAMINATION:

Higher motor functions - 
Conscious 
Loss of memory : Immediate memory loss, Short term loss 
Speech defects : Absent

Cranial Nerves -
Sensation of smell : Normal
Visual abnormality : Absent 
Difficultly in mastication : Absent 
Deviation of angle of mouth : Absent 
Taste sensation : Present
Vertigo, Deafness or tinnitus : Absent 
Dysphagia : Absent 
Wasting of tongue : Absent

Motor System - 
 Bulk of muscles ..... Normal bulk 
Upper limb : 
Right UL- 26 cm
Left UL- 26 cm 
Lower limb : No consent for lower limb 
Tone of muscles........ 
Upper limb : 
Biceps - Present 
Triceps - Present 
Lower limb : No consent for lower limb 
Power of muscles .........
Upper limb : Present 
Lower limb : Present 

Sensory System -
Temperature : Normal 
Pain : Normal 
Touch : Normal 
Vibration : Normal 


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