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
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