GM-5

December 27 th Case scenario.......

Hi, I am s.supriya  , 3rd bds   student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:A 55 year old male , occupation cattle worker ,came from gowraram to general medicine opd

Chief complaints:
Difficulty in lifting left upper limb & loss of speech no h/o mouth angle deviation
HISTORY OF PRESENT ILLNESS:
Patient was apparently Asymptomatic , But 10 days back difficulty in lifting left upper limb & loss of speech,then treatment at nalgonda hospital gradually recovered.
 Duration: 12 hours
Onset: sudden
Time of occurrence: work
Flaccid type of paralysis 
Weakness:
upper limb 
Proximal: present
Distal: present
Lower limb weakness: absent
Weakness of Trunk : absent 
Weakness of Neck : absent
H/o Sensory loss :
Touch sensation:present
Pain sensation: present
Timbling sensation: present
H/o loss of consciousness: present
Vomiting: present
Diarrhea: present
Headache: present
Blurring of vision present
 Burning micturition: present
Loss taste sensation
PAST HISTORY:
A know case of diabetes mellitus since 5 years
A know case of hypertension since 10 days from the day of paralysis
No h/o previous surgeries
No h/o asthama, epilepsy, cardiovascular disease
PERSONAL HISTORY:
Diet: mixed
Appetite: normal
Sleep: Adequate
No smoking
Alcohol Consumption: Occasionally
Bowel movements: Present
Bladder movement: absent
FAMILY HISTORY:
 Similar h/o present in his father
DRUG HISTORY:
Not significant


GENERAL EXAMINATION
Patient was conscious
Coherent
Cooperative
Poorly built
Moderately nourished
Pallor present
Clubbing cyanosis: absent
 DRUG HISTORY:
Not significant

SYSTEMIC EXAMINATION:

Cardiovascular system:

Cardiac sounds: S1, S2 heard

Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular Normal
Abdomen:

Shape: distended
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:

Conscious
Speech: absent
Coherent higher motor function s intact
INVESTIGATIONS:

   



PROVISIONAL DIAGNOSIS:
Acute Infarct Right caudate of occipital lobe & fronto parietal lobe.

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