A 70 year old male came with the complaints of generalised weakness of limb

14  April 2023

E LOG GENERAL MEDICINE 

Hi, I am Naalla Gayathri , 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

Date of admission - 12th April 2023

CHIEF COMPLAINTS:

Patient complaints of generalised weakness of right upper limb 1 year back and tremors of right upper limb,right lowerlimb and left foot.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 year  back,then he had generalised weakness of right upper limb which resulted in partial loss of activities and right side deviation of mouth with drooling of saliva.He was dependent on his wife for doing daily activities.His wife observed tremors in patient.And patient ocassionally experienced headache at bitemporal regions of both sides which radiates to occipital region may be 2 times a week and also tingling sensation in limbs.

PAST HISTORY:

Known case of hypertension since 10 years.

No history of diabetes, asthma, tuberculosis, epilepsy, thyroid.

He had a history of left leg injury 20 years back.

PRESENT HISTORY:

Diet:mixed previously but eating only veg from 1                year

Appetite: decreased 

Sleep: inadequate (sometimes due to headache)

Bowel: constipation from many years.Defecate                     only when he consume vaamu or any                          laxative syrup

Bladder: regular

Addictions: Alcohol since 20 years.Consumes 45                   ml a day.But he is not consuming since 1 yr.

             BD since 55 years i.e. from his childhood.

             He consumes 15 per day.

FAMILY HISTORY:

Mother had hypertension.

ALLERGIEC HISTORY:

No known allergies.

GENERAL EXAMINATION:

Patient was conscious, coherent and cooperative.

Oriented to time,place and person.

(But had short term memory loss.)

Pallor - absent.

No icterus

No cyanosis

No lymphadenopathy

No edema.