December 29th 

General medicine elog 

Hi , I am G Manish reddy ,3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio. 

 CHEIF COMPLAINTS 

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

HOPI 

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 and lower limb during midnight .Then he consulted nearby RMP 10 days ago where he was given some medications.Patient had a history of injury to the big toe followed by swelling of the right foot.Still the patient has no relief from the symptoms so he visited hospital on  27 December.

PAST HISTORY 

K/C/O Diabetes ,BP since 6 months 

N/K/C/O Asthma,TB,CAD,Epilepsy 

Patient complaints of occasional lacrmation 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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