A 40 year old female patient came with the chief complains of dry cough since one week and left upper and lower limb weakness since two years.
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.
A 40 year old female patient came with the chief complaint of dry cough since one week and weakness of upper and left lower limb since two years.
History of present illness.
Patient was apparently asymptomatic two years ago then she developed fever and next day while going to farm she developed sudden weakness of left upper limb and left lower limb
History of past illness.
K/c/o HTN since two years and is on medication.
CVA two years back
N/k/c/o DM Tb epilepsy asthma
Personal history.
Patient was previously a farmer by occupation.
Bowel movement is regular.
Bladder movements regular
Slee adequate
Diet mixed
No addictions
Family history.
Father had similar episodes and is a known case of HTN.
PHYSICAL EXAMINATION.
A. General Examination
The patient was conscious coherent cooperatove well oriented to time place and person .He was examined in a well ventilated room with consent taken Pallor is absent .
Icterus is absent.
No cyanosis
No clubbing of fingers
No lymphadenopathy
No malnutrition
No clubbing of fingers
No oedema of feet and hands.
Temperature: afebrile
Blood pressure: 190/110 mmHg
Respiratory rate : 18/ min
B. Cardiovascular system
No thrills
No cardiac murmurs
Cardiac sounds: S1 and S2
C. Respiratory system
dyspnea absent
No wheezing
No Vesicular breath sounds .
Position of trachea - central
D. Abdomen
Abdomen is scaphoid
No tenderness
No Palpable mass
Bowel sounds anew present
No bruits
No free fluids
E. Central nervous system
Patient was conscious and coherent well oriented to time, space and person
Speech is normal
Cranial nerves normal
Motor system normal
Sensory system normal
Glasgow scale normal
REFLEXES
Right. Left
Biceps ++ —
Triceps ++ __
Supinator ++ ++
Knee ++ —
Ankle ++ —
CEREBELLAR SIGNS
finger nose in coordination
Knee heal in coordination
GAIT
Normal.
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