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



SYSTEMIC EXAMINATION

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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