A40 years old male patients came to causality with chief complaint of weakness in right upper limb

This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.
CHEIF COMPLAINT :
 45 yr old male came to the casuality with the cheif complaint of weakness of right upper and lower limbs and slight deviation of mouth towards left in the morning
HISTORY OF PRESENT ILLNESS:
A 45 yr old male patient , construction worker by 
Occupation was apparently asymptomatic 2 days back and then developed 2 to 3 episodes of vomitings , food particles as contents and non blood stained .and then again asymptomatic till yesterday morning and then developed weakness of right upper and lower limb and mild deviation of mouth towards left .
patients also experienced headache , blurring of vision and giddiness.
---> patient normally wakes up at 6 am and
HISTORY OF PAST ILLNESS:
History of trauma 1month back and injury to upper right limb which resulted in pain and swelling and relieved on medication.
No history of diabetes ,hypertension ,asthma ,TB,epilepsy.
 PERSONAL HISTORY:
- Marital status : married 
-Diet:- mixed
-Appetite- normal appetite 
-Bowel and bladder movements - Regular
-Micturition : normal
-Sleep :- irregular
-Addictions:-patient has a habit of chewing gutka  and discontinued since 4 yrs
-Smoking - daily(2 packs a day)
-Alcohol : daily
-Drug addiction:- no
-Allergies :- no history of allergies.
FAMILY HISTORY :
no relevant family history
GENERAL EXAMINATION:
Patient was conscious non coherent and coperative moderately fit, moderately nourished and examined ina well lit room.

No Pallor, 
No Icterus,
No Cyanosis,
No Clubbing,
No oedema (pedal)
No Lymphadenopathy
VITALS :
Temp :- 98 ‘F
PR:- 89 bpm
BP: 120/90 mmHg
SpO2: 98% 
RR:- 20 cpm
SYSTEMIC EXAMINATION :
CVS : 
no thrills no murmurs
S1 and S2 are positive
RESPIRATORY SYSTEM :
vesicular breath sounds 
No dyspnea
No wheeze 
Central position of trachea
ABDOMEN :
Shape : scaphoid
No tenderness
Liver ,spleen -not palpable
CNS : 
Conscious
Speech : incoherent
Neck stiffness : no
PROVISIONAL DIAGNOSIS: 
Acute ischemic stroke involving left temporal, frontal and parietal lobe.
Investigations:
Hb : 16.6
Tlc: 9,900
Rbc: 5.59
PT count : 2.04
CUE :
Colour pale yellow
Appearance : clear
Pus cells : 3- 4
Epithelial  cells : 2-4
---:creatine : 0.9
Urea :23
Blood group: A positive
LFT :
Total bilirubin :1.32
Alt:12
Ast: 18
Alp:178
Total proteins:6.3
Serology:
Hbs ag : negative 
HIV 1&2 : negative
Anti Hcv ab's : negative 
---:Na+ :140
K+ : 3.9
Cl-  100
ECG
ULTRASOUND

Treatment

Comments

Post a Comment

Popular posts from this blog

A45 year old male patients came to causality with chief complaint of fever , abdomen pain , vomiting and lose stool

Image
CHIEF COMPLAINTS :    A 45 yr old male c/o fever since 5 days, abdominal pain , loose stools and vomitings since yesterday. HOPI: patient was apparently asymptomatic 5 days ago and then developed fever, which is low grade, not associated with chills and rigors and relieved on medication. He complains of diffuse pain abdomen since 11th October morning. He had 3-4 episodes of vomiting on the same day evening, food particles as content and non- bilious in nature .He had loose stools since evening the same day, which is of 5 -6 episodes and so he went to local hospital. He developed weakness of both upper and lower limbs and found to be having low potassium, correction was done and the weakness got improved. He now came with c/o abdominal pain , vomiting and loose stools. PAST HISTORY Not a k/c/o DM, Hypertension, Asthma, epilepsy, CAD, CKD.  He went for a General checkup 6yrs ago, where he was diagnosed as HIV positive. He was on ART .  He met with an accident 3yrs ago and got Right ankle
Read more

A 45 year male patients came to causality with chief complaint of yellowish discoloration of sclera

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. A 40 year old male who is a coconut vender came to casualty with c/o : • constipation since 10 days • Yellowish discoloration of sclera and urine from 3 days. • cough(dry cough) since 2 days. • throat pain sinc
Read more

A65 year old female patients came to causality with chief complaint of stomach while taking food

Image
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.  CHEIF COMPLAINT   : A 65yr old female patient  complaints of stomach  pain on taking food since 1month HISTORY  OF PRESENT ILLNESS  : A 65yr old female patient  who is aaganwadi worker by occupation was apparently  asymptomatic  1month ago then she noticed stomach pain  on taking food and relived on vomiting  and medication.  HISTORY OF PAST ILLNESS  : H /o hypertension since 20 yrs ( on medication ) No h/o asthma ,diabetes ,epilepsy, thyroid   H/o similar complaint 5yrs back FAMILY HISTORY  :  no relevant family history  PERSONAL HISTORY  :  Married  Diet : mixed Appetite : decreased  Sleep: adequate  Bowe
Read more