A 40 yrs old female came to hospital with chief complaints of dry cough and weakness in left lowerlimb and upperlimb

 Hi I am, A satyanarayana(roll no:12), 5 th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio

CHIEF COMPLAINT

A 40 yrs old female came to hospital with chief complaints of dry cough since one week and left lower limb and upperlimb weakness since 2 years

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic till 2 years ago then she developed fever and next day while going to farm she developed sudden weakness of left upperlimb and left lower limb

HISTORY OF PAST ILLNESS

K/c/o Hypertension since 2 years and on medication TELMA

CVA 2 yrs ago

N/k/c/o asthma, Tb , DM, epilepsy, thyroid disorders

Personal history.

Patient was previously a farmer by occupation.   

Bowel movement is regular.

Bladder movements regular

Sleep adequate

Diet mixed

No addictions 

No burning micturition

Family history.

Father had similar episodes and is a known case of HTN.

PHYSICAL EXAMINATION.

A. General Examination 

The patient was conscious coherent cooperatove well oriented to time place and person 

He was examined in a well ventilated room with consent taken

No pallor

No icterus

No cyanosis

No clubbing of fingers

No lymphadenopathy

No malnutrition 

No clubbing of fingers

No oedema of feet and hands.

VITALS

Temperature: afebrile 

Blood pressure: 190/110 mmHg

Respiratory rate : 18/ min

SYSTEMIC EXAMINATION

No thrills

S1 s2 are heard 

No cardiac murmers

No dyspnea 

No wheeze

Position trachea central 

Vesicular breathe sounds

Shape of abdomen is scaphoid

No tenderness

Liver not palpable 

Spleen not palpable

Central Nervous system:

Conscious and coherent 

Cranial nervers -normal

Tone                 Rt                  Lf 

UL                     N                   N

LL                      N                   N

Power               Rt                  Lt

UL                    5/5                 3/5

LL                     5/5                 3/5