general medicine

This is an online E log book to discuss our patients de-identified health data shared after taking his/his guardian signed informed consent . Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts with an aim to solve those clinical problems with collective current best evidence based input 



A 70 yr old male came to hospital with complaint of weakness in right upper and lower limb since  3 days.



HISTORY OF PRESENT ILLNESS : 


Patient was apparently asymptomatic 3years back when he has his first episode of right sided  upper and lower limb weakness and  was managed conservatively . 

Then he again had his second episode of right side UL and LL  weakness 1year back 

Managed conservatively.


HISTORY OF PAST ILLNESS : 


Patient is having hypertension frm past 1year.

No diabetes mellitus

No TB

No epilepsy

No asthma .


PERSONAL HISTORY : 


Patient occupation is cattle grazer.

His appetite is normal

Mixed diet.

Bowel movements are regular.

Micturition is normal.



FAMILY HISTORY : 

No significant history.




GENERAL EXAMINATION : 


No pallor 

No cyanosis

No lymphadenopathy 

No oedema of feet 


Temperature :  Afebrile

Pulse rate : 70/min

Respiration rate : 16 /min 

BP : 140 / 80 mm/Hg

spo2 : 98%



TREATMENT HISTORY : 


PATIENT has BP since 1year and he is using atenolol 25mg since 1yr.

No diabetes 

No asthma 



SYESTEMIC EXAMINATION : 


CVS : 


S1 and S2 heard.


Respiration is normal .


CNS : 


Patient is conscious

Speech : Patient is unable to speak but he is responding .

Reflexes are normal.


 

Treatment:
1) Tab ecosprin 150mg
2) Tab . clopridogel 75mg
Tab atrvastatin 40mg
Tab pancuronium 40mg
Tab atenolol 25 mg 
 physiotherapy of right UL and LL.

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