General medicine case 5

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37 K.sai likhitha , 39 k.meghana 

 Date of admission: 2 oct 2021

A 57 year old female who is a magam worker came to the chief complaint of weakness of the left lower and upper limb and deviation angle of mouth to the right side since 6 days.

History of present illness:

    Patient was apparently asymptomatic 6 days back before she developed weakness of left lower and upper limb and also deviation of the angle of the mouth to the right side since 2days

Before coming to our causality she joined the local hospital just weakness of the left upper and lower limb without deviation of angle of the mouth. She took the treatment for 4days there she became normal but later developed deviation angle of mouth then rush to our causality .

Past history:

 She had similar complaints in the past before 1year.

She has hypertension since 5years 

 She has diabetes mellitus since 4 years .

No h/o epilepsy 

  No h/o tb 

 Mo history of any previous surgery. 

Personal history 

Normal apetite

Mixed diet

Adequate sleep

Bowel and bladder -normal

 Takes alcohol occasionally. 

Family history:

   Similar complaints in the family with patients mother.

 Drug history:

   No allergy to known drugs. 

General examination:

Patient is conscious, coherent, co- operative

No signs of pallor 

no icterus

 no cyanosis,

 noclubbing

No edema

 no  lymphadenopathy.

Tremors are present. 

Vitals:

Temp: Afebrile
PR: 113 bpm
BP: 180/90mm HG
RR: 22 cpm

  Systemic examination:- 

Cvs:

 S1 s2 heard

Respiratory system:

No dysponea 

Position of trachea central.

Abdomen:

 Soft 

Non tender.

CNS:

Gait:Hemiplegic 

Cranial nerve intact 

Sensitive to touch and pain.

Provisional diagnosis:

 Monoplegia of the left  limb.

Investigations:

ECG:

Treatment:

1.IVF NS AND RL @50ML
2.T. METFORMIN 500MG 
3. T. ASPIRIN 150MG 
4. T. CLOPIDOGREL 75MG 
5.T. ATORVAS 40MG