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
