70 year old farmer



 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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. This E log book also reflects my patient-centered online learning portfolio.

A 70 year old male farmer, came to the hospital with chief complaints of weakness in the both upper and lower limbs since 1 week  

HISTORY OF PRESENT ILLNESS-  

Patient was apparently alright 1 week back, then developed weakness in both upper and lower limbs which was insidious in onset and gradually progressive. He was unable to perform daily activities. Associated with neck pain, and shortness of breath (Grade 3). Not associated with headache, vomiting or blurring of vision.  

Decreased urine output 2 days before onset of paralytic episode. 

PAST HISTORY : 

History of Hypertension since 10 years 

No history of Diabetes, tuberculosis, coronary artery disease, epilepsy, asthma 

PERSONAL HISTORY : 

Patient's wife died just before onset of symptoms (precipitating factor?)

Diet : mixed 

Appetite : reduced since 3 months. 

Sleep : adequate 

bladder movements : regular 

Bowel : constipation ( passes stools in every 2 days)  

No allergies 

Addictions :  alcohol on alternate days (360ml / sitting)  

FAMILY HISTORY : 

Wife died on Friday .

Son committed suicide 10 years ago. 

Osteoarthritis since 2 years .

TREATMENT / SURGICAL HISTORY : 

He underwent hernioplasty 15 years ago. 

And cataract surgery 6 years ago in right eye and 3 years ago in left eye. 

Antihypertensive drugs  since 10 years.

            PHYSICAL EXAMNINATION 

GENERAL EXAMINATION : 

I have examined patient in a well lit room and by taking patients prior consent.

patient is conscious, coherent, well oriented to time ,place and person .

No pallor, icterus, cyanosis ,clubbing, koilonychia,  lymphadenopathy .

VITALS : 

Temperature :afebrile.

Bp: 140/80mm of Hg 

PR : 80bpm

RR : 18cpm.

SYSTEMIC EXAMINATION: 

CVS : S1,S2 heard,  no murmurs. 

RS : BAE+ 

No additional sounds heard. 

P/ A : 

A soft palpable abdominal mass present .

CENTRAL NERVOUS SYSTEM  :

 patient is conscious, coherent well oriented to place time and person. 

CRANIAL NERVE : 

cranial nerves:             right.            Left 

 1 ( sense of smell)          +                   + 

2. ( visual acuity, field)   N.             N 

3,4,6 carnial nerves.       Intact.       Intact 

5 cranial nerve.              Intact.        Intact 

7 CN ( facial symmetry )    +              + 

8,9,10,11,12 CN.                  Intact.       Intact 

   

MOTOR SYSTEM : 

                                      Right.              Left. 

* Bulk :                       Normal.          Normal 

* Tone :                          N.                    N 

* power :                     

UL.                             Grade 4              Grade 4 

LL.                              Grade 4.             Grade 4

 * Deep tendon reflexes : 

Biceps.                          +3                   +3

Triceps.                         +3.                 +3

Supinator 

Knee.                             +3.                  +3

Ankle.                            +3.                 +3 

Plantar.   

Babinski sign. -             absent         absent

finger nose test- Past pointing. 

Sensory system- Intact. 

















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