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









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