General medicine E-log
58 yr old with stroke
58 year old male construction worker by occupational came with chief complaints ofBurning sensation at right upper half of the body since 2years
History of present illness
Patient was apparently asymptomatic 2years than one night he suddenly complained of loss of vision in both eyes and he developed weakness of right upper limb and lower limb and deviation of mouth to left side which is sudden in onset preceeded by 30-40 episodes of vomiting non-bilious , non-blood tinged, projectile which was associated with involuntary movements of both upper limbs and lower limbs , associated with frothing , tongue bite , outward fixation of left eye ball. After which patient went into coma for 3 months . He was taken to rk hospital Hyderabad treated there for 15 days than was brought back home . He was later taken to Khammam for treatment 3 times in a gap interval of 10 days still patient dint recover . Later they used some herbal medication and he regained consiousness slowly . He also was taken to the nalgonda hopistal for eye treatment during using the herbal medictaiom . From past one yr he had been using medication from miryalguda hospital .Now he complains of burning sensation in the right half of bodyy .
Past History:
K/c/o epilepsy since childhood not on any medication. Since 2years he is using medication for seizures and stopped since 2months.
K/c/o HTN since 2years, stopped medication since 2months.
N/k/c/o Diabetes,Tuberculosis,bronchial asthma.
Personal History:
Diet : Mixed
Appetite : Normal
Sleep : Normal
Bowel and bladder moments :Regular
Addictions: alcoholic since 20years , stopped 2years back .
Family History:
Not significant
General physical examination:
Patient is unconscious
Moderately built and nourished
.
Pallor: Absent
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy:absent
Pedal edema:absent Vitals:Temperature - 98F
PR :-80beats per minute
BP :- 150/100mm Hg
RR:-26 cycles per minute
GRBS:-135
SpO2-90%
Systemic examination:
Cardiovascular system:
S1S2 heard
No murmurs heard
Respiratory system:NVBS heard
BAE present
Central Nervous system:Higher mental functions: Level of consciousness : consciousSpeech: slurredNo signs of meningeal irritationCranial Nerves 3rd cranial nerve palsyExtra ocular movements restricted in temporal side right eyeMotor system
Tone Rt. Lt
UL decreased N
LL. Decreased N
POWER Rt. Lt
UL 4/5 5/5
LL. 4/5 5/5
Reflexes Rt. Lt
B +3 +3
T +3 +3
S + 2 +2
K + 3 +3
A + 2 +2
P FlexionSensory system
Rt. Lt
Pain N. N
Touch. N. N
Temperature. N. N
Vibration. N. N
Romberg's sign. Negative
Two point discrimination more than 4cm
Tactile localisation. N. N
Per Abdomen:
Soft,non tender No organomegaly
Investigations
Provisions diagnosis
CVA with right sided hemiparesisLeft sided medial rectal palsy
Treatment
Tab. Pregabalin 75 POTab. Aturvastat 20mgTab. Clopidogrel 75mgTab. Neurobion
58 year old male construction worker by occupational came with chief complaints of
Burning sensation at right upper half of the body since 2years
History of present illness
Patient was apparently asymptomatic 2years than one night he suddenly complained of loss of vision in both eyes and he developed weakness of right upper limb and lower limb and deviation of mouth to left side which is sudden in onset preceeded by 30-40 episodes of vomiting non-bilious , non-blood tinged, projectile which was associated with involuntary movements of both upper limbs and lower limbs , associated with frothing , tongue bite , outward fixation of left eye ball. After which patient went into coma for 3 months . He was taken to rk hospital Hyderabad treated there for 15 days than was brought back home . He was later taken to Khammam for treatment 3 times in a gap interval of 10 days still patient dint recover . Later they used some herbal medication and he regained consiousness slowly . He also was taken to the nalgonda hopistal for eye treatment during using the herbal medictaiom . From past one yr he had been using medication from miryalguda hospital .Now he complains of burning sensation in the right half of bodyy .
Past History:
K/c/o epilepsy since childhood not on any medication. Since 2years he is using medication for seizures and stopped since 2months.
K/c/o HTN since 2years, stopped medication since 2months.
N/k/c/o Diabetes,Tuberculosis,bronchial asthma.
Personal History:
Diet : Mixed
Appetite : Normal
Sleep : Normal
Bowel and bladder moments :Regular
Addictions: alcoholic since 20years , stopped 2years back .
Family History:
Not significant
General physical examination:
Patient is unconscious
Moderately built and nourished
.
Temperature - 98F
PR :-80beats per minute
BP :- 150/100mm Hg
RR:-26 cycles per minute
GRBS:-135
SpO2-90%
NVBS heard
BAE present
Sensory system
Rt. Lt
Pain N. N
Touch. N. N
Temperature. N. N
Vibration. N. N
Romberg's sign. Negative
Two point discrimination more than 4cm
Tactile localisation. N. N
