General medicine case discussion



Yamini
 
April 14th,2023
April 14  th 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 70year old male , occupation carpentor,came from budharam to general medicine opd

Chief complaints:
General weakness 

HISTORY OF PRESENT ILLNESS:
Depending on some one for daily activities
Weakness of right upper limb and right lower limb
Headache: bitemporal radiate to occipital region 
Onset: sudden
Weakness:
upper limb 
Proximal: present
Distal: present
Lower limb weakness: present
Weakness of Trunk : absent 
Weakness of Neck : absent
H/o Sensory loss :
Touch sensation:present
Pain sensation: present
Timbling sensation: present
H/o loss of consciousness: present
Vomiting: present
Diarrhea: absent
Headache: present
Blurring of vision absent
 Burning micturition: absent 

PAST HISTORY:
A know case of hypertension since 10 years 
No h/o DM, epilepsy,tb, bronchial asthma
PERSONAL HISTORY:
Diet: mixed
Appetite: decreased
Sleep: Inadequate
Alcohol Consumption: Occasionally
Smoking:BD 15 per day since 50 years.
Bowel movements: absent (constipation since many years)
Bladder movement: present

FAMILY HISTORY:
 His mother was hypertension 

DRUG HISTORY:
He was using
Amlodipine+Atenolol
Aspirin
Donepizil

GENERAL EXAMINATION
Patient was conscious
Coherent
Cooperative
Poorly built
Moderately nourished
Orinted to time,place and person
Pallor: present
Icterus: absent
Clubbing : absent
 Cyanosis: absent
Lymphadenopathy : absent
Edema: absent

SYSTEMIC EXAMINATION:

Central Nervous System:

Higher motor functions:
Conscious
Oriented to place , Time and person. 
Speech: present
Coherent higher motor function s intact.

Cranial Nerve Examination :
Sensation of smell: present
Visual abnormalities : Absent
Difficulty in mastication : absent
Deviation of angle of mouth: absent
Taste sensation: present
Vertigo, deafness or tinnitus : absent
Dysphasia : absent
Wasting of tongue: absent
Nystagmus: Absent
Light Reflux: Absent

Motor examination :
Bulk: normal
Tone -
Triceps & biceps : present
Power -
Limb,hand , shoulder: present

Sensory system:
Temperature: Normal
Pain: Normal
Touch: Normal
Vibration: Normal

   







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