A 70 yrs old male came to opd with chief complaints of slurring of speech and inability to walk

Hi, I am Satyanarayana,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

• 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

  Cardiovascular system 

  No thrills 

  No cardiac murmurs

  Cardiac sounds: S1 and S2

  Respiratory system

  dyspnea absent 

  No wheezing

  Vesicular breath sounds 

  Position of trachea - central

  Abdomen

  Abdomen is scaphoid

  No tenderness

  No Palpable mass 

  Bowel sounds are present 

  No bruits

  No free fluids

  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 gait.