Leftside limb pain
E LOG GENERAL MEDICINE
Hi, I am soumya , 6th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
* This is an ongoing case. I am in the process of updating and editing this ELOG aChief complaints and duration.
Chief complaints :
A 45 year old female , resident of nakrekal, housewife by occupation , came to the OPD with chief complaint of pain in the left side of neck, left hand and left leg since yesterday night
History of present illness :
Patient was apparently asymptomatic 3 months back then she developed pain in the left side of neck , left hand and left leg which is sudden in onset, gradually progressive, dragging type of pain.
No aggravating and relieving factors
No history of fever
History of past illness :
She is a known case of diabetes since 4 years and is on regular medication
Similar complaints in the past
3 episodes had taken place in the last three months which is subsided by medication given by local rmp
Pain abdomen sonce 15 days which is relieved on taking medications
No hypertension
No TB
No CAD
No epilepsy
No Asthma
No thyroid
Family history :
No significant family history
Allergies :
No allergies
Drug history :
Medications for diabetics since 4 years
Personal history :
Appetite is normal
Mixed diet
Bowel and bladder habits are regular.
Sleep is adequate.
No addictions.
PHYSICAL EXAMINATION :
A. General Examination
Oral consent is taken.
Examined in a well lit room.
Conscious , coherent and cooperative
Moderatly built and nourished
Pallor is absent
Icterus is absent.
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema is absent.
Vitals :
Temperature: afebrile
Pulse: 80 bpm
Respiration: 16/min
Blood pressure: 110/80mmhg
Spo2: 96%
PHYSICAL EXAMINATION :
A.Cardio vascular system :
Cardiac sounds : S1 and S2
No thrills
No murmurs
B.Respiratory system :
Position of trachea : centre
Breath sounds : vesicular
No added sounds.
C.Abdomen :
Shape of abdomen : normal
No tenderness
No palpable mass
No organomegaly
Tone , power of limbs are normal
Comments
Post a Comment