GENERAL MEDICINE 9
A 55 YEAR OLD MALE PATIENT CAME TO OPD WITH THE CHIEF COMPLAINT OF SWELLING OF THE RIGHT FOOT ND TINGLING SENSATION OF BOTH LEGS SINCE 1 WEEK
Hi I'm Soniya , 3rd sem medical student .This is an online elogbook to discuss our patients health data after taking her consent.This also reflects my patient centered online learningortfolio
HOPI
Patient was apparently asymptomatic 1 week ago
.Then he had sudden weakness in the right upper limb and right lower limb .
Patient was unable to walk and lift his right upper limb.Then he consulted nearby RMP 1 week ago where he was given some medications.
Patient had a history of injury to the big toe followed by swelling of the right foot.
Still the patient has no relief from the symptoms so he visited to our hospital
PAST HISTORY:
Aknown case of dm and hypertension since 6 months
Patient complaints of occasional lacrimation from the left eye
No history of asthama . epilepsy.TB
FAMILY HISTORY
No relevant family history
PERSONAL HISTORY
Mixed Diet
Appetite- normal
Sleep adequate
Bowel and bladder movements-normal
Occasional drinker but stopped drinking since 6 months
GENERAL EXAMINATION
Patient is conscious,coherent and cooperative
moderately built and well nourished
No pallor
No icterus
No clubbing of fingers
No cyanosis
No Lymphadenopathy
Pedal edema present
VITAL SIGNS
BP-120/80mmhg
PulseRate- 64 bpm
SpO2 -98%
SYSTEMIC EXAMINATION
CVS:
S1 and S2 sounds heard
No murmurs
No thrills
RESPIRATORY SYSTEM
dyspnoea
No wheezing
Central location of trachea
Vesicular breath sounds
No scar on inspection
ABDOMEN
Abdomen is scaphoid
No tenderness
No palpable mass
Normal hernial orifices
Non palpable liver or spleen
Bowel sounds are heard
CNS
Conscious
Speech- normal
no neck stiffnes
Cranial system - intact
Motor system - intact
Sensory system - intact
Facial palsy positive
PROVISIONAL DIAGNOSIS
Right hemiparesis ,Facial palsy,Right lower limb cellulitis
