This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning.
DEIDENTIFICATION -
The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
CASE DISCUSSION -
82 year old female patient came with C/O weakness of lower limb, Neck and shoulder pain since along with pedal oedema and fever since 10 days.
HOPI-
Patient was apparently asymptomatic 10 days back then she developed weakness of the lower limbs, sudden in onset, non-progressive.
Also, C/O fever since 10 days low-grade not associated with chills and rigours, continuous, relieved on medication. C/O pedal oedema since 10 days, pitting type, from ankle to knee.
No C/o chest pain, palpitations, cough, cold, LOC
PAST HISTORY-
K/c/o of HTN since 10 years(On medication- Telma 40mg)
Not a k/c/o DM, Epilepsy, Seizures, CVA, Asthama, TB.
PERSONAL HISTORY-
Addictions- Nil.
Appetite- Normal
Diet: Vegetarian
Sleep: Adequate
Bowel and bladder movements: Regular
Family History:
Not significant.
General Examination -
Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
She is conscious, coherent and cooperative.
Built & nourishment-Moderate
Icterus - Present
Pallor +
No cyanosis
No clubbing
No edema
No lymphadenopathy.
Vitals:
Temp: 98.2 F
Bp: 100/60 mmHg
PR: 102 bpm
RR: 18 cpm
SpO2: 98% on RA
Systemic Examination -
CVS :
S1 S2 present
No murmurs
RESPIRATORY SYSTEM;
B/l symmetrical chest
Trachea - Central
B/l air entry present
NVBS heard
ABDOMEN:
Shape of abdomen: Scaphoid
Soft, non tender.
No rigidity or guarding.
BS+
CNS :
NFND, HMF intact
GCS- 15/15
Investigations-
Treatment-
1) Tab. Ultracet PO/SOS
2) Tab. Telma-AM PO/OD
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