80y/F presented with difficulty in walking since two days.
E LOG GENERAL MEDICINE.
Hi, I am Anvitha, 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
- This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING!
* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.
CASE SHEET.
Chief complaints and duration.
The patient presented with the complaints of difficulty in walking since two days. It was apparently asymptomatic two days back and developed cough and shortness of breath . She was taken to the hospital and relieved for sometime and presented with similar complaints.
History of present illness.
Patient was apparently asymptomatic two days back and then at night around 12:00am she suddenly developed giddiness and SOB for which RMP came and checked her BP and at that time systolic was 200 mm hg (according to the patient) . She tried to walk with her stick (which she was using since one year due to fear of falling) for which she can’t walk and due to her weakness in the right lower limb for which she was taken some medication ( not known) and then there was no improvement in the complaints and denied for admission.
History of past illness.
The patient came with the same complaints.
Not a known case of diabetes, HTN. (Detected with HTN two days back)
No history of Thyroid, EAD and CVA
Using medication for decrease in appetite.
Personal history.
Patient is labourer by occupation.
Bowel movement is regular.
Micturition is normal.
No history of Allergy.
Addictions: Habit of toddy stopped 10 years back.
Habit of tobacco daily once stopped 3 months back.
Family history.
No significant family history.
Menstrual history.
Hysterectomy done 60 years back because of white discharge.
PHYSICAL EXAMINATION.
A. General Examination
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No malnutrition
No clubbing of fingers
No oedema of feet
No dehydration
Temperature: 98.6 F
Pulse: 88/ min
Respiration: 16/min
SYSTEMIC EXAMINATION
B. Cardiovascular system
No thrills
No cardiac murmurs
Cardiac sounds: S1 and S2
C. Respiratory system
No dyspnea
No wheezing
Vesicular breath sounds .
D. Abdomen
Normal
E. Central nervous system
The patient was conscious coherent and cooperative.
F. Examination of teeth and oral cavity.
Blackish discolouration of tongue.
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