Hi, I am Manasvi Peddineni, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio.
Case Scenario:
70 year old male farmer by occipation, Resident of Nalgonda came to hospital with chief complaints of inability to lift left upper and lower limb since morning.
History of present illness:
-patient was apparently asymptomatic 7 months back then developed bilateral pedal edema for which he went local hospital then was diagnosed with Right mild hydroureteroephrosis, Gall bladder calculi, Fatty Liver.
- he developed generalized weakness 20 days back.
- On 24 August 2022: After his dinner at 8 PM, he went to bed 9 PM.
- On 25 August 2022 Morning when he was about to wake up from the bed, he could not lift his left Upper and Lower limb which was Sudden in onset and there is loss of speech since morning then he was immediately Hospitalised.
-There is no H/o fever,head injury,Vomiting, Loss of consciousness, palpitation,chest pain.
History of past illness:
- no similar complaints in past.
-known case of diabetes and Hypertension since one year and was on regular medication.
- No H/o Tuberculosis, Epilepsy,Asthma.
Personal History:
-Diet - Mixed
-Appetite -Normal
-Bowel and bladder -Regular.
-Sleep - Adequate
-Addictions: consumes Alcohol since 40 years and Smoker consumes 3 to 4 biddi per day.
Family History:
No signicant Family history
General Examination:
-Patient is conscious ,coherent ,cooperative
-He is moderately built and nourished.
-Pallor: Absent
-Icterus: Absent
-Cyanosis: Absent
-Clubbing: present
-lymphadenopathy: absent
Pedal edema: absent
Vitals : on the day of admission
-Temperature: Afebrile
- Pulse rate: 103 bpm
-Respiratory rate: 16 cpm
- BP: 180/90 mmHg
-SpO2: 96% on Room air
-GRBS :160mg/dl
Systemic Examination:
CNS Examination:
-Face is turned towards Right side.
-Loss of speech
-Cranial nerves : nasolabial fold on left side is less prominent. Deviation of mouth to Right side. Forehead wrinkles are absent on left side.Other cranial nerves are normal.
-Power:
Right Left
Upper Limb 4/5 0/5
Lower Limb 5/5 0/5
-tone : hypotonia of left lower limb. Hypertonia of left upper limb
-reflexes :
right Left
Biceps Present Absent
Triceps Present Absent.
Supinator Present Absent.
Knee Present. Absent
Ankle Present. Absent
Cardiovascular System:
S1 ,S2 heard , no murmurs.
Respiratory System:
BAE Present.
Abdomen:
Soft and non tender , bowel sounds +
Clinical Images:
Investigations: