General medicine case discussion

B.Varshitha 

8th semester 

Roll no.21

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individukal patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.

A 78 year old female patient resident of  came to the hospital with cheif complaints of loss of speech since 1month

and unable to swallow since 1month

History of present illness 

Patient was apparently asymptomatic 1month back then she found by her daughter fallen on ground unable to walk and speak but she was conscious 

treated by RMP for 3days  and then admitted in suryapet private hospital as her condition was not improving 

She was treated in private hospital and diagnosed as ischemic stroke

speech was returned and able to swallow  and walk with support after treatment and shifted to government hospital after 4days due to high cost in private hospital 

She was admitted in government hospital for 12days and discharged after giving prescription to medication for 1month

She was on medications for 1week and again developed decreased in speech and unable to swallow since 3-4days and brought to KIMS hospital yesterday night 

Past history 

No history of Similar complaints in past

K/C/O HTN since 3years and medications Amlodipine 

N/K/C/O Diabetes,epilepsy,TB,asthma

Personal history 

• Diet : mixed

• Appetite: normal

• Sleep : Adequate 

• Bowel habits: normal 

• Bladder habits : normal 

No Addictions 

Family history 

NO H/O HTN, Diabetes,epilepsy,TB,asthma

Physical examination 

General examination 

Patient conscious coherent and well oriented to place and time 

• No pallor 

• No Icterus is present 

• No cyanosis

• No lymphadenopathy

• No clubbing of fingers

• Moderately built and moderately nourished

Vitals

Temperature: Afebrile 

Pulse rate: 66/min

BP: 70/60mm of Hg

RR:12cycles per min

SYSTEMIC EXAMINATION

CVS

RESPIRATORY SYSTEM

No Dyspnea

No wheezes

Trachea-Central

Breath 

Abdominal examination 

No palpable mass

No free fluid 

No palpable spleen and liver

CNS

Conscious

Coherent

Not Cooperative

Speech-

No neck stiffness

Sensory system- Normal

Motor system- 

PROVISIONAL DIAGNOSIS 

INVESTIGATIONS