GENERAL MEDICINE ELOG 6
A 70 year old male patient came to opd with the chief complain of slurring of speech and inability to walk.
E LOG GENERAL MEDICINE.
Hi, I am Harsha Chahdana,5th 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 as and when required
CASE SHEET.
Chief complaints and duration.
A 70 yr old male patient came with the chief complain of unable to walk since two years and difficulty in speech since two years and difficulty in swallowing food and passing urine and stools.
History of present illness.
Patient was apparently asymptomatic 4 years ago then he developed generalised body weakness and disability to walk and progressive slurring of speech.
He developed difficulty in swallowing liquids
and taking time to pass urine.The condition was progressive.
There is no associated pain and seizures and deviation of mouth.
History of past illness.
History of trauma four years back where he fell down from the tractor while doing field work and had a leg fracture. Surgery was done and a rod was placed.
K/C/O HTN since one year and is on medication TELMISARTAN. He stopped using it after two months.
N/K/C/O DM , asthma , epilepsy, Tb.
Personal history.
Patient was a farmer by occupation. Married
Appetite normal
Bowel and bladder movements regular
Micturition - normal
addictions : chronic alcoholic since 30 years
Tobacco since 20 years stopped ten years back.
Family history.
No significant family history.
PHYSICAL EXAMINATION.
A. General Examination
The patient was conscious coherent and well oriented to time place and person and was examined in a well lit room.
Pallor is absent.
Icterus is absent
No cyanosis
No clubbing of fingers
No lymphadenopathy
No malnutrition
No clubbing of fingers
No oedema of feet and hands.
SYSTEMIC EXAMINATION
B. Cardiovascular system
No thrills
No cardiac murmurs
Cardiac sounds: S1 and S2
C. Respiratory system
dyspnea absent
No wheezing
Vesicular breath sounds
Position of trachea - central
D. Abdomen
Abdomen is scaphoid
No tenderness
No Palpable mass
Bowel sounds are present
No bruits
No free fluids
E. Central nervous system
The patient was conscious coherent and cooperative.
Speech - slurred
No neck stiffness
Kernigs sign absent
Cranial nerves intact.
Sensory system normal
Glassgow scale : 15/15
Right Left
Tone UL N N
LL N N
Power UL 5/5 5/5
LL 5/5 5/5
Reflexes:
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Supinator + +
Knee 3+ 3+
Ankle 2+ 2+
Cerebellar signs:
No finger nose coordination
No knee heel coordination
Gait : slow and shuffling
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