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