GENERAL MEDICINE E-log

 NAME:A Sanvith

ROLL NO:09

Welcome and greetings to every one who are visiting my blog. This is A sanvith of 8th semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

CHIEF COMPLAINTS:

A 55 year old female who was farmer by occupation came to the opd

Numbness and pain since 10days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10days back and she noticed decreased sensations on left side of her limbs and including her face which was insidious in onset gradually proggressive.

Their was a dragging type of pain and also with decreased sensations.

No history of any fever and trauma.

Whe she was normal she used to wake up at 6am and she used to go to work and return back at 6pm and she used to have 3times meals in a day. 5 years ago first time complaints have started as decresed in sesations of the limbs and then she went to hospital and took some medication and the pain was relieved and again after stopping medication after some time .she again started developed similar complaints,one year ago she visited a neurophysician and got prescribed with some medicines which have shown relief to her ,those were given only for two months and again she came for the appointment with neurophysician again but currently he is unavailable so she wants  medication that might reduce her symptoms .

HISTORY OF PAST ILLNESS:

N/k/c/o DM,HTN,TB,ASTHMA,EPILEPSY

No history of previous surgeries

PERSONAL HISTORY:

Diet: Mixed

Appetite: Normal

Sleep: adequate 

Bowel and bladder:Regular

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Patient was conscious,coherent and cooperative and well oriented to time and place.

Moderately built and nourishment 

No pallor, icterus, cyanosis, clubbing and generalized lymphadenopathy.

VITALS:

PR:76BPM

BP: 124/80 mmhg

R/R: 16CPM

Provisional diagnosis:

Left sided hemiplegia

Previous H/o stroke