Short Case General Medicine Practical Examination
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A 65 old male presented to opd on 19th Jan 2023 with the chief complaints of slurring of speech
weakness of left upper limb since from yesterday
complain of pedal edema
History Of Present illness :
1.19 year ago patient underwent surgery
2.7 years ago diagnosed hypertension, also diagnosed with gastro esophageal reflex disease( acid reflex)
Prescribed- NexproRD 40mg for GERD
3.7 MONTHS ago diagnosed with chronic diarrhoea
4.1 month ago patient slipped and fell in bathroom and observed swelling on scalp region
5.1 day ago patient observed difficulty in walking, slurring of speech, and pedal edema
Pitting type , Extent till ankle
Patient was apparently asymptomatic 6 months back then he had h/o loose stools 6 to 7 episodes daily ,low quantity , yellow colour
No association with pain abdomen,no mucus in stool
No blood in stool
History of fever 2 episodes in the past 6 months
No history of nausea vomiting
History of past illness :
History of acute ischemic stroke
K/c/o Hypertension from 7 years
N/K/C/O diabetes mellitus ,epilepsy,tuberculosis
H/o trauma 1 month back (slip and fell in bathroom)
H/o surgery 18 years back for hernia
He used to take medications for hypertension since 7 years
Telma-H
Personal History:
Marritual Status
Diet: Mixed
Appetite : Decreased
Bowel and bladder movements : Regular
Micturition: Decreased since 3 days
Sleep : Adequate
No known allergies
Addictions : Patient drinks alcohol daily
He takes 90ml of alcohol 1-2 times per day
Family History : No relevant family history
General Examination :
I have taken the consent of the pateint and examined pateint in well lit room in supine or sleeping position
The patient is Conscious Incoherent and Non-coperative ,poorly nourished
Well oreinted to time place and person
Pallor present
No icterus
No cyanosis
No Clubbing
No Generalized lymphadenopathy
History of pedal edema
Vitals :
Temperature: Afebrile
BP - 140/80 mm hg
PR - 80beats per minute
Respiratory Rate - 18 cycles/minute
Clinical Pictures :
1.CVS -
s1 s2 sounds heard
no murmers
2.RESPIRATORY SYSTEM
On Inspection :
No Scars are seen
No Dropping of Shoulders
Chest is Bilaterally Symmetrical
Postion of trachea Central
On palpation :
All inspectory findings are confirmed
Position of Trachea - central
Apical impulse in left 5th inter coastal space ,1cm medial to mid clavicular line.
Vocal fremitus- felt on supra and infra scapular area
Abdomen: No organomegaly
4 . CNS
TONE : UL LL
N N
Hypo N
Motor
Wrist - 0/5
Higher mental functions
- Conscious +
- Oriented to time+,place+ and person+
- Memory - intact
- Speech - slurred
Cranial nerve examination
1olfactory sense - normal
2- visual acuity present,
R L
Direct reflex + +
Indirect reflex + +
3,4,6 - no ptosis Or nystagmus
5- corneal reflex present
7-No loss of nasolabial folds, forehead wrinkling present
8- Normal
9,10- position of uvula is central
11- sternocleidomastoid contraction present
12- no deviation of tongue
Investigations :
Ultrasound :
ECG
Cerebro vascular accident with hypertension
Treatment
Tab clopidogrl 75 mg OD
Tab ecospirin 75 mg OD
Tab atarvostat 20 mg OD
Tab telma
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