Gen med case discussion

 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. 


CHEIF COMPLAINTS 

A 60 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 was unable to walk and so he had injury to the right big toe 7 days ago.Still the patient has no relief from the symptoms so he visited to OPD on  27 December2022.

PAST HISTORY 

K/C/O Diabetes ,BP since 6 months 

N/K/C/O Asthma,TB,CAD,Epilepsy 

Patient complaints of occasional lacrimation 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






Comments

Post a Comment

Popular posts from this blog

A 17 year old came with tremors

 A 17 year came to OPD with chief complaints of tremors in the right leg since 2 and half months HOPI  Patient was apparently asymptomatic 2 and half months back.he then developed tremors which was sudden in onset and continuous . Tremors were seen when he touches the sole to the ground and disappears when foot is lifted from ground.tremors were also relieved during sleep . He also complained of bilateral leg pain when he walks for more distance . He also has complaints of headache since 5 days. PAST HISTORY N/K/C/O-DM ,HTN ,asthma ,TB ,CAD,CVA FAMILY HISTORY Insignificant PERSONAL HISTORY Mixed- diet Appetite -normal Bowel and bladder movements -regular Sleep-adequate No addictions No allergic history  GENERAL EXAMINATION Patient is examined in a well lit room  Moderately built and well nourished No Pallor  No icterus No cyanosis No clubbing of fingers No lymphadenopathy No pedal edema VITAL SIGNS Temp-afebrile Pulse rate -74bpm  Resp rate -16cpm  Bp-110/70mmhg
Read more

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 61 year old male patient who is a farmer by occupation resident of yadadribhuvanagiri, came to CKD for dialysis  having symptoms of severe backpain,fever and SOB  HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic 1 month back  1 month back he developed severe bodypains mostly back pain associated with itching  He also has symptoms of giddiness and headache  With these symptoms he went to meet RMP doctor and the doctor suggested antibiotics still his symptoms were not decreased  On 12-12-2022 he went to hospital near mothkur there he was diagnosed with blood infection  On  17-12-2022 he went to hospital near Janagam as his pains were not reduced there he was diagnosed with kidney problem doctor suggested to undergo dialysis but the hospital
Read more