General medicine case discussion

 General medicine elog 


Hi , I am M sumanth reddy of  3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio. 




CHEIF COMPLAINTS 


A 55 year old male who is farmer by occupation resident of achampeta came to OPD with cheif complaints of swelling of the right foot and tingling sensation of both right leg and right upper limb since 10 days


HOPI 


Patient was apparently asymptomatic 10 days ago.Then he had sudden weakness in the right upper limb and right lower limb.Patient was unable to walk and lift his right upper limb.Then he consulted nearby RMP 10 days ago where he was given some medications.Patient had a history of injury to the big toe followed by swelling of the right foot.Still the patient has no relief from the symptoms so he visited Kims on 27 December.


PAST HISTORY 


No history of Diabetes ,BP since 6 months 


No history of Asthma,TB,CAD,Epilepsy 


Patient complaints of occasional lacrmation from the left eye 


FAMILY HISTORY


No relevant family history


PERSONAL HISTORY


Mixed Diet 


Appetite- normal


Sleep adequate


Bowel and bladder movements-normal 


Occasional drinker but stopped drinking since 6 months 


GENERAL EXAMINATION


Patient is conscious,coherent and cooperative


moderately built and well nourished



No pallor  


No icterus 


No clubbing of fingers


No cyanosis 


No Lymphadenopathy


Pedal edema present.        


VITAL SIGNS 


BP-120/80mmhg


Pulserate- 64 bpm


SpO2 -98%


SYSTEMIC EXAMINATION


CVS 


S1 and S2 sounds heard 


No murmurs


No thrills 


RESPIRATORY SYSTEM


No dyspnea


No wheeze


Central location of trachea

Vesicular breath sounds 


ABDOMEN 


Abdomen is scaphoid


No tenderness


No palpable mass 


Normal hernial orifices 


Non palpable liver and spleen


Bowel sounds are heard


CNS




Conscious 


Speech- normal


Signs of meningeal irritation - 


no neck stiffness


no kerming's sign


Cranial system - intact 


Motor system - intact 


Sensory system - intact 


Facial palsy positive



Cerebeilar signs


    Finger nose- not in coordination


    Knee heel - not in coordination  


INVESTIGATIONS


USG report 





PROVISIONAL DIAGNOSIS 


Right hemiparesis ,Facial palsy,Right lower limb cellulitis


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