GM e-log

 his is online E log book to discuss our patients health data shared after taking his guardians informed consent form


I have been  given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findingsfindings investigations and come with a diagnosis and treatment plan.       A73 yr old female resident of yennaram came to OPD with chief compliants of weakness of RT UL and Ll. 


History of present illness
Pt was asymptomatic till yesterday morning after having breakfast she slept and woke up suddenly developed weakness in RT UL and Ll and unable to move her legs .she also had slurring of speech she also unable to move her head to left.admitted to our hospital yesterday. 
No H/o of deviation of mouth.
No history of involtary micturation /defecation






Daily routine:
She wake up at 6am and do daily work like sweeping house but she doesn't cook.she eats afternoon and sleeps and in the evening drink tea and eats dinner at 9pm.she follows this routine till yesterday.

History of past past illness:
K/c/o of hypertension since 15yrs and on regular medication ATENELOL 500mg and changed to CINOD- T. 
She visited nalgonda local hospital 4mnths back because of knee pain and she has also had gastric problem and on medication.
No H/o of diabetes,asthama ,TB 
No H/o Nausea vomiting 







Personal history:
Diet:mixed noramal appetite
Sleep: improper,use sleeping pills
Bowel movement: regular
Micturation; Normal
Additions:nil
No allergic history


Family history:
No relevant family history


Drug history:
Hypertension:CINOD-T and other medication and other medication
-rabeprazole sodium and levusupride for gastric problems. 
Etozola plus for insomnia and decreased anxiety
   


General examination::
Patient is conscious, coherent and coperative well oriented with time and place.
Well nourished and built.
There is no signs of 
  Cyanosis 
   Pallor
    Clubbing
     Icterus 
     Lymphadenopathy and edema.
    
Vitals: 
Temparature:98.6degree farenheit 
Pulse rate:76 per minute
Respiratory rate:16 per minute 
BP:145/95
Spo2:96%
   
Systemic examination:
CNS:
Conscious
Slurred speech
No neck stiffness(no signs of meaningal irritation)


Musle tone :
          RT.                         Lt
UL.     Decreased.        Noramal
LL.    Noramal.           Noramal

Power: 
              RT.                 Lt
UL.       2/5.            4/5
LL         2/5.           4/5

Cvs: s1and S2 normal
       No murmors


 Respiratory syste
m: no dyspnoea 
               -No wheeze
              -central trachea
Abdomen:
 Obese abdomen
 No palpable mass 
 No tenderness
 No free fluid
 Spleen not palpable

Provisional diagnosis:
RT hemeparesis 2° to acute infaract in left. putamen 
K/c/o hypertension



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