GENERAL MEDICINE ELOG

 General medicine elog 

Hi , I am Anamika Maiti ,3rd semester student.  This is an online elog book to discuss our patients health data after taking his consent.  This also reflects my patient centered online learning portfolio.

A 60 YEAR OLD MALE WITH LEFT LOWER LIMB MONOPLEGIA SECONDARY TO ACUTE ISCHAEMIC STROKE.

A 60 year old male who is an agriculture labourer  by occupation a resident of Nalgonda, came to the OPD with complaints of weakness in left lower limb since 20 days.

HISTORY OF PRESENT ILLNESS:

The patient has complaints of weakness in left lower limb since 20 days. The patient was apparently asymptomatic 2 months ago. Then he developed giddiness at his workplace associated LOC for 10 minutes and woke up by his wife who took him home. Then he was fine for 1 month. Then he developed pain in the left lower limb at night for which he took treatment (not documented). Then the pain continued for 5 days which is dragging type. Then he developed weakness in that limb associated with involuntary micturition of one episode.

No H/O of  seizures, up rolling of eyes, tongue bite, left upper limb weakness, slurring of speech, facial deviation, fever, neck rigidity.

PAST HISTORY : 

N/K/C/O  DM, HTN, TB, Epilepsy , Asthma.

PERSONAL HISTORY :

H/O intake of alcohol since 14 years of age for 45 years daily 180-200 ML.

H/O smoking since 14 years of age  20 beedies per day for 45 years. 

FAMILY HISTORY : Nil

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. 

No pallor, icterus, cyanosis , clubbing of fingers, lymphadenopathy and oedema of feet.

Thyroid normal

Vitals:

Temperature- 98.6F

BP- 140/90 mmHg

HR- 72 bpm

RR- 18 cpm

SpO2 - 98% on RA

SYSTEMIC EXAMINATION:

CVS : S1S2 heard , No murmurs

RS : NVBS, BAE+

PA : SOFT NT

CNS :

 TONE        RT                LT

  UL            NORMAL    NORMAL 

 POWER    RT                LT

  UL            5/5               5/5

  L/L           5/5               4/5

REFLEXES  RT      LT

B  ++  ++

T  ++  ++

S  ++  ++

K  ++  +++

A  ++  ++

P    FLEXOR  FLEXOR

CEREBELLAR SIGNS:

Rombers sign - Negative

Finger to nose - No incordination

Finger nose finger- No incordination

Investigations :

PLAIN MRI BRAIN- multiple small infarcts involving right paracentral lobule , left parietal lobe and right frontal lobe.

2D ECHO- trivial TR NO MR/AR

NO RWMA NO ASMS SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTIONS 

Blood group B+

RBS 179

CUE ALBUMIN + PUS CELLS  2-3

HAEMOGRAM HB 12.7 TC 11000 N 64  L30 E2  M4 B0

PCV 37.8  MCV 87.2  MCH 29.4  MCHC 33.7  RBC 4.3  PLATELET 2.6

 LFT TB 0.70  DB 0.20  A:G 1.31  AST 38  ALT 41  ALP 165  TP 6.4  ALBUMIN 3.6

RFT - UREA 42  CREAT 2.3  URIC ACID 7.9  CA 9.3

PHOSPHORUS 3.3  NA 142  K 4.0  CL 105

Investigations 

USG ABDOMEN - Rt renal cortical cyst

                                Lt renal calculus 

                                Lt grade III RPD

CXR - N study

ECG - No specific findings