A 73 year old female patient who is presented with weakness and immovable right extremities

I am Shreya Gaddam(rollno: 38) 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.

A 73 year old female patient who is agriculturer by occupation came to opd with cheif complaint of weakness in right upper limb and lower limb.

HISTORY OF PRESENT ILLNESS -
Patient was apparently asymptomatic 2 days back.
She had her meal at 12:00 pm and took rest.
She woke up at 2:00 pm and she felt weakness and immovable right extremities.
Since yesterday slurring of speech is observed.

PAST HISTORY -
Patient is hypertensive since 15 yrs.
No epilepsy
No TB
No diabetes
No asthma

DRUG HISTORY -
Regular medication of T. ATENOLOL 50 mg.

PERSONAL HISTORY -
Dirt -mixed
Appetite - normal
Bladder and Bowel movement - regular
Sleep -using sleeping pills since 2-3months 
No known allergies
No history of addictions

FAMILY HISTORY-
No relevant family history 

PHYSICAL EXAMINATION -

GENERAL EXAMINATION -
Patient is conscious, coherent, comfortable and co-operative
Moderately built, moderately nourished
No pallor 
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers 
Pedal edema absent

 VITAL SIGNS-
Temperature: 98.6F
Pulse: 78bpm
BP: 180/110mm hg 
Respiratory rate: 16cpm
SpO2: 96%

SYSTEMIC EXAMINATION 
CVS:
Cardiac sounds: S1 and S2
No thrills
No cardiac murmurs

RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sounds

ABDOMEN-
Abdomen is obese
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 
SENSORY- intact 
MOTOR-         
Power        
                              Right             Left

Upper limb
Lower limb 

Tone            
                              Right             Left
 
Upper limb
Lower limb

Reflexes 
                      
Biceps
Triceps
Supinator 
Knee
Ankle

PROVISIONAL DIAGNOSIS -
Right hemiparesis secondary to acute infarct in left putamen.

INVESTIGATIONS DONE-
Hemogram,CVE,BGT, FBS,PLBS,HbA1C,RFT,LFT, 2D echo, colour doppler.

TREATMENT -
deviation of tongue to the right and mouth to the left

Comments

Post a Comment

Popular posts from this blog

27 year old female with chief complaints of generalised weakness and headache

Hi, I am Gaddam shreya of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio. The patient’s consent was taken verbally prior to history taking and examination of her condition. A 27 year old female student came to OPD with the cheif complaints of generalised weakness since 1 month, headache since 1 month. HISTORY OF PRESENT ILLNESS - Patient was apparently asymptomatic 1 month ago. Then she developed generalised weakness. History of weight loss, decreased food intake, increased menstrual bleeding and cycles are regular. Headache since 1 month which is insidious in onset, gradually progressive, pain is localised to frontal region especially on the left side, non radiating, no aggravating factors, headache relieved on medication. Recurrence of headache is observed. PAST HISTORY Not a known case of diabetes, hypertension,asthma,TB,CAD,
Read more

A 55 year female patient came to opd with chief complaints of generalised edema and decreased urine output

Image
Hi, I am Gaddam shreya of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio. The patient’s consent was taken verbally prior to history taking and examination of her condition.  55 year old female patient who is housewife and does household chores came to general medicine opd with chief complaints of generalised pedal edema and decreased urine output. HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic 2 years ago. Then she noticed blurred vision in both eyes. She consulted a local doctor and he referred to other doctor in Hyderabad. There she was diagnosed with diabetic retinopathy and underwent a surgery for right eye and improved her vision and was told that her left eye vision can't be improved by surgery. And 3 months back she developed bilateral pitting type of pedal edema which is gradually progressed to presen
Read more

42 year old female came to general medicine opd with chief complaints of pedal edema

Hi, I am Gaddam shreya of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio. The patient’s consent was taken verbally prior to history taking and examination of her condition. A 42 year old female patient who is housewife and does household chores came  to general medicine opd with chief complaints of pedal edema. HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic one month back. Then she noticed pedal edema, vomiting and visited local hospital and serum creatinine level observed is 4.5mg/dl. 15 days back she went to local hospital again as the symptoms are not reduced. Then she was referred to hospital in  Hyderabad.There they observed serum creatinine level raised to 14.4mg/dl, then she was suggested to start dialysis.  One sitting of dialysis done on 14/12/22. On 15/12/22  AV fistula surgery for dialysis is done. The
Read more