A 60 year old male came to general medicine OPD with the cheif complaints of tingling sensation of right leg and upper limb

Hi, I am M. Sohith Mahadeva Reddy of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.



The patient’s consent was taken verbally prior to history taking and examination of his/her condition.


 

A 60 year old male who is farmer by occupation resident of achampeta came to OPD with cheif complaints of swelling of the right foot and tingling sensation of both right leg and right upper limb since 10 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 10 days ago.Then he had sudden weakness in the right upper limb and right lower limb.Patient was unable to walk and lift his right upper limb.Then he consulted nearby RMP 10 days ago where he was given some medications.Patient was unable to walk and so he had injury to the right big toe 7 days ago.Still the patient has no relief from the symptoms so he visited to OPD on  27 December2022.

PAST HISTORY 

K/C/O Diabetes ,BP since 6 months 

N/K/C/O Asthma,TB,CAD,Epilepsy 

Patient complaints of occasional lacrimation from the left eye 

FAMILY HISTORY

No relevant family history

PERSONAL HISTORY

Mixed Diet 

Appetite- normal

Sleep adequate

Bowel and bladder movements-normal 

Occasional drinker but stopped drinking since 6 months 

GENERAL EXAMINATION

Patient is conscious,coherent and cooperative

moderately built and well nourished

No pallor  

No icterus 

No clubbing of fingers

No cyanosis 

No Lymphadenopathy

Pedal edema present 





VITAL SIGNS 

BP-120/80mmhg

Pulserate- 64 bpm

SpO2 -98%

SYSTEMIC EXAMINATION

CVS 

S1 and S2 sounds heard 

No murmurs

No thrills 

RESPIRATORY SYSTEM

No dyspnea

No wheeze

Central location of trachea

Vesicular breath sounds 

ABDOMEN 

Abdomen is scaphoid

No tenderness

No palpable mass 

Normal hernial orifices 

Non palpable liver and spleen

Bowel sounds are heard 

CNS 


Conscious 

Speech- normal

Signs of meningeal irritation - 

no neck stiffness

no kerming's sign

Cranial system - intact 

Motor system - intact 

Sensory system - intact 

Facial palsy positive





 Cerebeilar signs

    Finger nose-  not in coordination

    Knee heel - not in  coordination  



INVESTIGATIONS

USG report 





PROVISIONAL DIAGNOSIS 

Right hemiparesis ,Facial palsy,Right lower limb cellulitis







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