GENERAL MEDICINE CASE STUDY

Hi, I am laharisha, 8th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. 


A 58 yr old male hailing from miryalguda ,a construction worker came to the general medicine ipd with chief complaints of burning sensation at right upper half of the body since 2 yrs.


HISTORY OF PRESENTING ILLNESS:

patient was apparently asymptomatic 2 years back then he developed weakness of right upper limb and lower limb and deviation of mouth to left side which is sudden in onset preceded by 30-40 episodes of vomitings,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

HISTORY OF PAST ILLNESS:

K/C/O epilepsy since childhood not on any medication.since 2 yrs he is using medication for seizures and stopped since 2 months 

Klc/0 htn since 2 yrs ,stopped medication since 2 months

N/k/c/o DM ASTHMA TB THYROID

Personal History:


Diet : Mixed 


Appetite : Normal


Sleep : Normal


Bowel and bladder moments :Regular 


Addictions: alcoholic since 20 yrs stopped two yrs 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 :-78 beats per minute 


BP :- 150/100mm Hg


RR:-26 cycles per minute


GRBS:-135


SpO2-90%


Systemic examination:


Cardiovascular system: 


Inspection-


Shape of chest-Normal  

No precordial bulge.


No dialated veins,scars and discharging sinuses.


No visible pulsations.


Palpation-


 Apical beat felt in 5th intercostal space.


No parasternal heave and thrills


Auscultation-


S1S2 heard 


No murmurs heard


Respiratory :bilerateral air entry present


CNS EXAMINATION:

HIGHER MENTAL FUNCTIONS:

level of consciousness: conscious

Speech:slurred

Signs of meningeal irritation:no

Cranial nerves:

3rd cranial nerve palsy -extraocular movements restricted in right eye

Right sided 

temporal loss

MOTOR SYSTEM:

Tone Rt.       Lt


Ul.      Decreased.       Normal 


LL.decreased.              Normal 



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

SENSORY SYSTEM:  

                            Rt.                    Lf

Pain                    N.                      N

Touch.                 N.                      N

Temperature.       N.                    N

Vibration.           N.                       N

Rombergs sign.    NEGATIVE.     NEGATIVE

Two point discrimination:HE CAN DISCRIMINATE ONLY UPTO 4 CMS

Tactile localisation.    N.              N


Per Abdomen:


Soft,non tender 

No organomegaly


Provisional diagnosis:

CEREBROVASCULAR ACCIDENT with right sided hemeparesis


Treatment:

Tab.pregabalin 75 mg po

Tab.atorvastat 20 mg 

Tab clopidogrel 75 mg

Tab.Neurobio



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