General Medicine Case Discussion
December 23,2022
treament:
Case scenario.......
Hi, I am M Yamini , 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.
CASE SHEET:A 60 year old female occupation farmer came from ramannapet to general medicine OPD.
Chief complaints:
Patient suddenly falls from bed presented with involuntary movement s of left limb & left hand
Deviation of Mouth
Biting of tongue
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 days back , suddenly she developes involuntary movements of both left upper & lower limbs.
Biting of tongue
Deviation of Mouth
H/o seizure episode
Duration:10mints
Onset: Sudden
Time of occurrence: Sleep
Weakness of limb
Upper limb:
Proximal: present
Distal: present
Lower limb
Proximal: present
Distal: present
Trunk: present
Neck: present
No h/o fasciculation/atrophy
No h/o Sensory loss
Touch sensation: present
Pain sensation : present
No h/o loss of consciousness
Aura : positive
No bowel & bladder disturbences
Frequency: 1 st time
No h/o suggestive etiology
Fever present
PAST HISTORY:No h/o DM, hypertension,
Epilepsy, Asthma ,cvd,
No h/o previous surgeries
PERSONAL HISTORY:
Diet:mixed
Bowel & Bladder movement s : present
Sleep:adequate
Alcohol: occasional consumption
FAMILY HISTORY:
In Significant
GENERAL EXAMINATION:
Patient was conscious coherent cooperative poorly nourished poorly built
SYSTEMIC EXAMINATION:
Cardiovascular system:
Cardiac sounds: S1, S2 heard
Respiratory system:
No: dyspnea
No :wheezing
Breath sounds heard: Normal vesicular sounds
Abdomen:
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious
Speech: present
INVESTIGATIONS:
Biochemical investigations:
PROVISIONAL DIAGNOSIS:
Focal Seizures
