Case history-05



 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual 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. 

A 75 year old female came to the OPD with the chief complaints of deviation of mouth and generalised weakness.

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 2 days ago then complaints of weakness and noticed deviation of mouth towards left side to which she was admitted to local hospital.She was relieved on medication and got discharged.Then she had noticed the deviation of mouth again and was brought to the OPD.

HISTORY OF PAST ILLNESS:

She went to a local hospital for checkup 3 years ago where she was diagnosed with diabetes mellitus and hypertension. She is not a known case of bronchial asthma,epilepsy and tuberculosis.

PERSONAL HISTORY:

-The patient has no loss of appetite

-She takes mixed diet

-She has normal bowel and bladder movements 

-No sleep disturbances 

-The patient takes alcohol occasionally  and consumes non smoking form of tobacco daily since 20 years

FAMILY HISTORY:

- There are no similar complaints in the family members

TREATMENT HISTORY:

-The patient is on medication for diabetes and hypertension 

-She is not a known case of drug allergy 

 GENERAL EXAMINATION:

-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

-No edema of feet

VITALS - temperature:98.9F

-pulse rate:76bpm

-respiration rate:18/min

-bp:90/60

-grbs:26mg%

SYSTEMIC EXAMINATION:

CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

RESPIRATORY SYSTEM 

- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds

PER ABDOMEN 

- abdomen is not tender

- bowel and bladder sounds heard

- no palpable mass or free fluid

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal

INVESTIGATIONS
















Consent form 


-patient has denied to take any clinical images

TREATMENT  

•23-10-21

IVF dextrose 25%

Tab shelcal  po/OD 

Tab oroferx cut po/BD

Inj erythropoietin 4000IU weekly once 

•24-10-21

Tab nodosis 500mg

Tab shelcal 500mg po/od

Tab oroferx 

•25-10-21

Tab shelcal-500mg po/od

Tab oroferx 

Tab nodosis 


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