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 : Mamatha. N

Roll no : 65

2020 Batch

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 back. 

One year back patient 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 unconscious. 

After one month after paralysis he was aware of his situation. He had 2 episodes of headache , bilateral in a week 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