Gm-12

 I'm Soumya donthi (rollno: 31) 5 th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.

A 73 year old female patient who is agriculturer by occupation came to opd with cheif complaint of weakness in right upper limb and lower limb.

HISTORY OF PRESENT ILLNESS -

Patient was apparently asymptomatic 2 days back.

She had her meal at 12:00 pm and took rest.

She woke up at 2:00 pm and she felt weakness and immovable right extremities.

Since yesterday slurring of speech is observed.

PAST HISTORY -

Patient is hypertensive since 15 yrs.

No epilepsy

No TB

No diabetes

No asthma

DRUG HISTORY -

Regular medication of T. ATENOLOL 50 mg.

PERSONAL HISTORY -

Dirt -mixed

Appetite - normal

Bladder and Bowel movement - regular

Sleep -using sleeping pills since 2-3months 

No known allergies

No history of addictions

FAMILY HISTORY-

No relevant family history 

-

GENERAL EXAMINATION -

Patient is conscious, coherent, comfortable and co-operative

Moderately built, moderately nourished

No pallor 

No icterus

No cyanosis

No general lymphadenopathy

No clubbing of fingers 

Pedal edema absent

 VITAL SIGNS-

Temperature: 98.6F

Pulse: 78bpm

BP: 

Respiratory rate: 16cpm

SpO2: 96%

SYSTEMIC EXAMINATION 

CVS:

Cardiac sounds: S1 and S2

No thrills

No cardiac murmurs

RESPIRATORY SYSTEM:

No dyspnea

No wheeze

Central location of trachea

Vesicular breath sounds

ABDOMEN-

Abdomen is obese

No tenderness

No palpable mass

Non palpable liver and spleen

Bowel sounds are not heard

CNS-

Patient is conscious