43M with weakness

This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.





43 year old male , constructor by occupation came to casualty with the 



C/O - weakness of right upper and lower limb in the morning 

Slight Deviation of mouth towards left side.



HOPI-

A 43 old male patient construction worker by occupation , was apparently asymptomatic 2 days back and then developed 2-3 episodes of vomitings, food particles as content and non blood stained and asymptomatic till morning 8:00 am and then developed weakness of right upper and lower limb and mild deviation of mouth towards left. 

Patient also experienced Headache , blurring of vision and giddiness.



Daily routine- patient generally wakes up at 6:00am every morning 





HISTORY OF PAST ILLNESS-

H/o trauma one month back 

Injury to upper right limb resulted in pain and Swelling , subsided on medications.



No h/o DM,

Hypertension 

Asthma 

TB

Cardiac problems

Epilepsy





PERSONAL HISTORY-

Marital status- married



Diet:- mixed



Appetite- normal appetite 



Bowel and bladder movements - Regular



Micturition- normal



Sleep :- adequate 



Addictions:-patient has a habit of chewing gutka 4 years ago.



Smoking - patient smokes 2 packets of beedi per day.

H/o smoking since 15 yrs



H/o Alcohol - since 15 yrs

Patient drinks daily



Drug addiction:- no



Allergies :- no h/o allergies



FAMILY HISTORY-



No relevent family history..



GENERAL EXAMINATION -



Patient was conscious, non coherent,moderately fit, moderately nourished and Cooperative, and examined in a well lit room.



No Pallor, 



No Icterus,



No Cyanosis,



No Clubbing,



No oedema (pedal)



No Lymphadenopathy



Vitals

Temp :- 98.1F



PR:- 89bpm



BP: 120/90mmHg



SpO2: 98% at RA



RR:- 20 cpm



SYSTEMIC EXAMINATION-



CVS - no thrills 

           No murmurs

           S1 S2 +



Respiratory- breath sounds - vesicular

                      No dyspnea

                      No wheeze

Position of trachea- central



Abdomen - shape - scaphoid

                 No tenderness

                 No palpable mass

                 No free fluid

Liver and spleen - not palpable

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