I am Saranya ,currently an intern posted in the department of General Medicine
Greetings to all my readers;
This is an elog documenting the patients that I witness during my Rotatory Internship Postings to enforce a greater patient centered learning
The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
CONSENT : An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.
ACKNOWLEDGMENT
I convey my regards to Dr. Lohith and Dr.Narsimha Readdy ( Resident , Department of General Medicine ) for guiding me regarding the case .
Documentation :
is being done on 20th July 2023
(Updates will be done later in the future with dates mentioned for the same.)
INTRODUCTION :
My patient is a 75 year old man , resident of a rural district of South India
CHIEF COMPLAINTS :
A 75 yearold male came to casualty with chief complaintsof weakness of left upperlimb and lowerlimb since 2 days
Clinical pictures
Lateral and Front profile
HOPI:
Patient was apparently normal 2 days back he then developed weakness of left upperlimb and lowerlimb which was insidious in onset and gradual in progression.
No C/O deviation of mouth
Neck pain+
No C/O headache, vomiting, blurring of vision
C/O constipation-passes stool in every 2days
Decreased urine output since 2 days
No pedal edema, facial puffiness
Mild SOB grade2
Biopsychosocial Corelation:
Patient used to live in their village house with his wife ,son ,daughter in law and grandson
Until 6 months from today, he used to go to his fields everyday for ploghing and seed sowing work but his wife began falling sick, she developed paresis ,inability to move and became completely confined to the bed .
To support her and also carry out certain chores ,he stopped going to the fields and stayed at home the entire time ,taking care of the wife.
His wife passed away 5 days back which left a big mark on him and he kept complaining that he wasn't feeling fine since then , after which his situation worsened and 1 day back he was brought to our medical institution
USUAL DAILY ROUTINE AND DERANGEMENT DUE TO DISEASE
He would get up 6 am in the morning, freshen up, have breakfast at 7 am and go off to the agricultural fields for work, he would come back home for lunch at 1 pm ,take some rest and go back to his fields for another hour or two at around 3 pm.
Evenings usually he used to spend time with his family and neighbours ,have his dinner at around 7 pm and go to bed.
Although the patient has been experiencing these symptoms from around 1 week back but it has severely deranged his daily life, unlike before he is unable to any of this daily work independently and needs help all round the clock.
PAST HISTORY:
Patient was diagnosed as hypertensive 3 days back but not put on any medication
N/K/C/O DM, TB, epilepsy, CVA, CAD, thyroid disorders and bronchial asthma
EXAMINATION:
Patient is conscious and oriented
PR:96bpm
BP:120/80mmHg
RR:14cpm
RS:BAE +no added sounds
CVS:S1, S2 heard. No added sounds
P/A:soft, nontender
Cns examination :
Patient is conscious , coherent and oriented to time ,place and person.
Higher mental functions are intact.
Patient has neurogenic bladder which was releived after insertion of foleys catheter.
Tone -normal in all four limbs
Power rt lt
4-/5 4-/5
4-/5 4-/5
Reflexes
B T S K A P
++ ++ + + + Flexion
++ ++ + + + Flexion
Neurogenic bladder
Note : on 19/7/23 evening , Patient accidentally hit the wall and suffered a laceration in the frontal region of the head.
Suturing and wound care was done for the same.
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