General medicine case 5
October 06, 2021
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
Date of admission: 2 oct 2021
A 57 year old female who is a magam worker came to the chief complaint of weakness of the left lower and upper limb and deviation angle of mouth to the right side since 6 days.
History of present illness:
Patient was apparently asymptomatic 6 days back before she developed weakness of left lower limb and also deviation of the angle of the mouth to the right side since 2days because of the deviation slurring of speech is observed.
Before coming to our causality she joined the local hospital just weakness of the left lower limb without deviation of angle of the mouth. She took the treatment for 4days there she became normal but later developed deviation angle of mouth then she rushed to our causality .
Past history:
She had similar complaints in the past since 1year.
She has hypertension since 5years
She has diabetes mellitus since 4 years .
No h/o epilepsy
No h/o tb
No history of any previous surgery.
Personal history
Normal apetite
Mixed diet
Adequate sleep
Bowel and bladder -normal
Takes alcohol occasionally.
Family history:
Similar complaints in the family with patients mother.
Drug history:
No allergy to known drugs.
General examination:
Patient is conscious, coherent, co- operative
No signs of pallor
no icterus
no cyanosis,
noclubbing
No edema
no lymphadenopathy.
Tremors are present.
Vitals:
Temp: Afebrile
PR: 113 bpm
BP: 180/90mm HG
RR: 22 cpm
Systemic examination:-
Cvs:
S1 s2 heard
Respiratory system:
No dysponea
Position of trachea central.
Abdomen:
Soft
Non tender.
CNS:
Gait:Hemiplegic
Cranial nerve intact
Sensitive to touch and pain.
Provisional diagnosis:
Monoplegia of the left lower limb.
Investigations:
ECG:
Treatment:
1.IVF NS AND RL @50ML
2.T. METFORMIN 500MG
3. T. ASPIRIN 150MG
4. T. CLOPIDOGREL 75MG
5.T. ATORVAS 40MG
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