A 70yr old patient came with chief complaints of unable to walk since 2 years
Hi I am,Anirudh manne(Roll no 11), 5th 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 complaints and duration.
A 70 yr old male patient came with the chief complain of unable to walk since two years and difficulty in speech since two years and difficulty in swallowing food and passing urine and stools.
History of present illness.
Patient was apparently asymptomatic 4 years ago then he developed generalised body weakness and disability to walk and progressive slurring of speech.
He developed difficulty in swallowing liquids
and taking time to pass urine.
The condition was progressive.
There is no associated pain and seizures and deviation of mouth.
History of past illness.
History of trauma four years back where he fell down from the tractor while doing field work and had a leg fracture. Surgery was done and a rod was placed.
K/C/O HTN since one year and is on medication TELMISARTAN. He stopped using it after two months.
N/K/C/O DM , asthma , epilepsy, Tb.
Personal history.
Patient was a farmer by occupation. Married
Appetite normal
Bowel and bladder movements regular
Micturition - normal
addictions : chronic alcoholic since 30 years.(Tobacco since 20 years stopped ten years back.)
Family history.
No significant family history.
PHYSICAL EXAMINATION.
General Examination
The patient was conscious coherent and well oriented to time place and person and was examined in a well lit room.
Pallor is absent.
Icterus is absent
No cyanosis
No clubbing of fingers
No lymphadenopathy
No malnutrition
No clubbing of fingers
No oedema of feet and hands.
SYSTEMIC EXAMINATION
Cardiovascular system
No thrills
No cardiac murmurs
Cardiac sounds: S1 and S2
Respiratory system
dyspnea absent
No wheezing
Vesicular breath sounds
Position of trachea - central
Abdomen
Abdomen is scaphoid
No tenderness
No Palpable mass
Bowel sounds are present
No bruits
No free fluids
Central nervous system
The patient was conscious coherent and cooperative.
Speech - slurred
No neck stiffness
Kernigs sign absent
Cranial nerves intact.
Sensory system normal
Glassgow scale : 15/15
Right Left
Tone UL N N
LL N N
Power UL 5/5 5/5
LL 5/5 5/5
Reflexes:
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Supinator + +
Knee 3+ 3+
Ankle 2+ 2+
Cerebellar signs:
No finger nose coordination
No knee heel coordination
Gait : slow and shuffling gait.
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