General medicine case2

A 57 year male patpatient complaints of giddiness and swinging to right
September 14 ,2022


Hi,I am A.poojitha 3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio. 

                   CASE SHEET 

Chief Complaints:
A 57 years old male patient auto driver by occupation resident of suryapet came to op.
.Hypertension with excessive sweating for 10days
.Giddiness, difficulty in walking, swinging to right.

HISTORY OF PRESENT ILLNESS:
He was asymptomatic 5days back and then developed pain and swelling of bilateral lateral malleolus for which he visited local RMP for which he received an injection followed by which he developed excessive sweating and the next day he developed excessive sweating and giddiness and difficulty in walking, associated with swinging to right,for which he went to local hospital and  CT was done and medications were given.Later,he perceived objects as two(diplopia)and it got resolved by its own after 30min.

HISTORY OF PAST ILLNESS:
Blood pressure @ presentation:170/100mmHg
No diabetes 
No Asthma 
No Tuberculosis 
No blood transfusion
No surgeries 

DRUG HISTORY:
No drug history

ALLERGY HISTORY:
No allergy history

PERSONAL HISTORY 
Apetite:normal
Bowel: regular
Micturition:normal
Diet: non-vegetarian 

HABITS:
Alcohol-chronic alcoholic for 20yrs and stopped  2yrs back
Tobacco:Beedi smoker for 22yrs
Beetal pan:no
Betel nut:no

PHYSICAL EXAMINATION 
Pallor:no
Cyanosis:no
Icterus:no
Lymphadenopathy:no
Clubbing of fingers/toes:no
Oedema of feet:no
Dehydration:no

VITALS:
Temperature:98.6c/f
Pulse rate:86/min
Respiration rate:16/min

PROVISIONAL DIAGNOSIS:
ACUTE INFERIOR CEREBELLAR INFARCT

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