General medicine E-log

32 CH SRILEKHA, 8th sem

This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.

58 year old male construction worker by occupational came with chief complaints of

Burning sensation at right upper half of the body since 2years

History of present illness

Patient was apparently asymptomatic 2years back then he developed weakness of right upper limb and lower limb and deviation of mouth to left side which is sudden in onset preceeded by 30-40 episodes of vomiting non-bilious , non-blood tinged, projectile which was associated with involuntary movements of both upper limbs and lower limbs , associated with frothing , tongue bite , outward fixation of left eye ball. 

Past History:

K/c/o epilepsy since childhood not on any medication. Since 2years he is using medication for seizures and stopped since 2months. 

K/c/o HTN since 2years, stopped medication since 2months. 

N/k/c/o  Diabetes,Tuberculosis,bronchial asthma. 

Personal History:

Diet : Mixed 

Appetite : Normal

Sleep : Normal

Bowel and bladder moments :Regular 

Addictions: alcoholic since 20years , stopped 2years back .

Family History:

Not significant 

General physical examination:

Patient is unconscious 

Moderately built and nourished.

Pallor: Absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent 

Vitals:

Temperature - 98F

PR :-80beats per minute 

BP :- 150/100mm Hg

RR:-26 cycles per minute

GRBS:-135

SpO2-90%

Systemic examination:

Cardiovascular system: 

S1S2 heard 

No murmurs heard

Respiratory system:

NVBS heard

BAE present

Central Nervous system:

Higher mental functions: 

Level of consciousness : conscious

Speech: slurred

No signs of meningeal irritation

Cranial Nerves 

3rd cranial nerve palsy

Extra ocular movements restricted in temporal side right eye

Motor system

Tone           Rt.                 Lt

UL            decreased           N

LL.           Decreased             N

POWER          Rt.                 Lt

UL                   4/5                 5/5

LL.                  4/5                  5/5

Reflexes         Rt.                   Lt

B                    +3                 +3

T                    +3                 +3

S                     + 2                +2

K                     + 3               +3

A                     + 2               +2

P                       Flexion

Sensory system 

                          Rt.                   Lt

Pain                    N.                   N

Touch.                 N.                  N

Temperature.        N.                 N

Vibration.              N.                 N

Romberg's sign.  Negative

Two point discrimination  more than  4cm 

Tactile localisation.      N.          N

Per Abdomen:

Soft,non tender 

No organomegaly

Provisions diagnosis

CVA with right sided hemiparesis

Left sided medial rectal palsy

Treatment 

Tab. Pregabalin 75 PO

Tab. Aturvastat  20mg

Tab. Clopidogrel 75mg

Tab. Neurobion