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






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