56 Kancharla Mahendra

 e-log

July 18, 2022

This 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 findings
 investigations and come with a diagnosis and treatment plan. 

 A 73 yr old female resident of Yennaram came to OPD with chief complaints of weakness of Rt UL & LL .
  
History of present illness:
Pt was asymptomatic till yesterday morning after having her breakfast she slept and was woke up,suddenly developed Weakness in Rt UL and LL and unable move her legs.She also had slurring speech.Also Unable to Turn her head to left. She admitted our Hospital yesterday.  
No H/o Deviation of Mouth.
No H/o involuntary Micturition/Defaecation.

  
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 8pm and sleeps at 9pm.She Followed this routine till yesterday.


History of past illness: 
K/c/o of hypertension since 15yrs & on regular medication ; Atenolol 50mg & changed to Cinod T
 She visited Nalgonda local Hospital 4 months Back because of knee pain and also had gastric problem and on medication 
No H/o of diabetes  Asthma Tb 
No H/o  nausea vomiting 

Personal History:

Diet: Mixed Normal Appetite 

Sleep:Improper.Use Sleeping Pills 

Bowel movement: regular

Micturition: Normal

Addictions: Nil

No allergic History 

Family history:

No relavent family history.

Drug History:
Hypertension: Cinod T 
And Other medications: 
-Rabeprazole Sodium and levosurpride- Gastric problems.
-Etizola plus- for insomnia and decrease Anxiety 
 

General Examination:

Patient is conscious,coherent and co operative well oriented with time and place .

Well nourished and built

There are no signs of

Cyanosis

Pallor

Clubbing

Icterus 

Lymphadenopathy 

Edema 

Vitals:

Temperature: 98.6 degree Fahrenheit

Pulse rate: 76 per min

Respiratory rate: 16 per min

BP: 145/95

SpO2: 96% 
 
Systemic Examination:

CNS:
-conscious 
-slurred speech
-no neck stiffness ( no sign of meningeal irritation)

 Muscle Tone:
                       Rt                     lt
    UL       Decreased        Normal
    LL        Normal              Normal


  Power:
                     Rt                     lt
      
       UL        2/5                 4/5
       LL        2/5                 4/5
   
CVS:
-S1 S2 +
-no mumurs 

Respiratory system:
-no Dyspnoea 
-no wheeze 
-central trachea 

 Abdomen:
-obese Abdomen 
No palpable mass 
No Tenderness 
No free fluid 
Spleen not palpable 
 

Provision Diagnosis:
 Rt. Hemiparesis 2° to acute infarct in the left.putamen
And K/c/o of HTN
















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