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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