39 G Sadhguna

 General medicine elog 

Hi , I am G.Sadhguna,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.

A case of 60 old male patient who is a farmer by occupation a resident of Putapaka Yadadri,came to OPD with complaints of weakness in lower limbs and giddiness

History of present illness.     

Patient was apparently asymptomatic 8 daysback 

 Dizziness for 30 min on and off in the morning Headache                                    

weakness since 7 days.                                              Hypertensive 

Unable to walk since 8 days

Difficult in speaking since 7 days  

3 episodes of vomiting 

Body pains present 

Headache is also present

No fever

Past history

Hypertensive since 4 yrs on medication 

N|K|C|O  CAD ,epilepsy,TB,DM,Asthma 

Personal history 

Appetite- normal 

Diet - mixed 

Bowel and bladder movements- decreased urine output (3 days ago)

Sleep- reduced ( 2 hrs a day )

Addictions - has been a occassional toddy  drinker 

Family history 

Not relavant 

General  Examination 

Conscious,coherent and coperative 

Pallor present 

No icterus,cyanosis, clubbing of fingers ,lymphadenopathy,and oedema of feet 

Vital signs 

Temperature - 98.6 F

Pulse rate- 98bpm

Respiratory rate-22 cpm

Bp-150/80 mmHg 

SpO2 -99% 

RBS- 143 mg/dl

Systemic examination

CVS

Circulation S1 S2 positive 

RS

Breathing BAE positive 

Airway is clear 

Provisional Diagnosis 

The patient is diagnosed with clot in the Brain