A 70 year old male with weakness of right upper & lower limbs and c/o aphasia

A 70 year old male with weakness of right upper & lower limbs and c/o aphasia

July 27,2023

Hi,I am poojitha Ankamgari 5th 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 70 year old male patient came with C/O weakness of Right UL and LL since 1 year C/o aphasia since 6months

HOPI:
patient was apparently asymptomatic 1 year back then he developed weakness of Right UL and LL, and was admitted in hospital( MRI /CT not done)

C/O loss of speech 6 months back, which is sudden in onset,non progressive,no aggravating and relieving factors.

No C/O SOB, palpitations, orthopnea,PND NoC/o pain abdomen, decreased urine output,pedal edema, fever, burning micturition, loose stools/ vomiting

 PAST HISTORY:

K/c/o right sided hemiparesis (CVA) 
K/c/o HTN since 1 year and on regular
medication (T.Amlong 5mg) 
Not a k/c/o DM, epilepsy, asthma,TB.

PERSONAL HISTORY:

Married
 Appetite - normal
Mixed diet
Bowel movement - regular
Normal micturition
No known allergies 
Addictions - regular consumption of alcohol 

FAMILY HISTORY: 

not significant 

GENERAL EXAMINATION:
Patient is concious, coherent and cooperative, well oriented to time, place and person.
No pallor, icterus,cyanosis, clubbing, lymphadenopathy,edema.

Vitals

Temperature - afebrile
Bp-90/70mmhg
 PR-88 bpm
RR-16cpm
Spo2- 99%
GRBS-134mg/dl

Systemic examination:
Cardiovascular System-
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System 
 no dyspnea 
No wheezing
central trachea
vesicular breath sounds
Abdomen
Scaphoid shaped abdomen 
 No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds -yes
CNS
Patient was conscious
Normal - aphasic
Tone-
                      R.                    L
UL           Hyper.         Normal
LL.          Hyper.         Normal

 Power-
UL.            4/5.            . 4/5

LL.             3/5.            . 4/5

REFLEXES:

Biceps       +2.                +2
Triceps      +1.                +1
Supinator  +1.                +1
Knee          +3.                +2       
Ankle         +1                 +1
Planter       Flexor.           Flexor

INVESTIGATIONS:
ECG-

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