General medicine case 5

 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome".

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 






  

Comments

Post a Comment

Popular posts from this blog

GM case 9

Image
  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment" A 27 year old male who is student from nalgonda came to the opd with chief complaints of pedal edema  since 2years . He also had vomiting and decreased urine output since 1mon History of present illness:   Patient was apparently asymptomatic 2yrs back then he developed persistent vomiting for about 2mon ,then he noticed bilateral pedal edema of pitting type which is insidious in onset ,for which he visited to local hospital and got to be told have some kidney issue and received med
Read more

GM CASE 6

Image
  This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome". K.meghana 39 , k.Sai likhitha 37  Date of admission:18/09/2021  39 years old male who doesn't have any proper occupation came with the chief complaints of abdominal discomfort and SOB since 3days.   History of present illness:   Patient has similar complaints since 5 years . Before diagonosing he had fever and loss of appetite since 1mon and also with cough, cold and throat infection along with back pain  and he visited local hospital where they identified is creatinine hig
Read more

GM case -4

Image
 Date of admission : 9 /08/2021 A 60 year old male who is an agriculture worker came with cheif complaint of swelling of hands and leg , shortness of breath since 1year . History of present illness:   Patient was asymptomatic 1year back before  he developed swelling of legs and hand but he neglected it later so it become progressive with  shortness of breath and decreased urine output.   Past history: Decreased urine output 1year back   Hypertension since 3years. No history of diabetes No histoy of epilepsy No history of tb No history of any previous surgeries  Personal history: Diet -mixed Sleep-decreased Appetite-decreased Bladder-regular Bowel: regular No addictions.  Family history:  No similar complaints in the family are seen. Drug history:  No allergy to known drugs.  General examination:    Patient is coherent,cooperative,conscious.    No pallor     No cyanosis    No lymphadenopathy   No malnutrition     No pedal edema   No clubbing of fingers.   Vitals:  Temp :98.4°f  Pulse ra
Read more