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

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