Case history-2
Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
A 65 year old male to hospital with chief complaint of loss of speech and unresponsive ness at 8am yesterday.
History of present illness:.
The patient wakes up early in the morning.
Patient was asymptomatic 6 months back.
Patient woke up at 6:30 in the morning.He had his his breakfast.The patient noticed weakness of L,UL, LL.
On such complains the son also observed that the mouth had got deviated to the right side and made the patient lie down on a bed.
After an hour when the son tried to wake up the patient he noticed that the patient was not speaking and not moving his L, UL, LL.
The patient experienced similar episode 8months back.
History of past illness:
Family history:
Personal history:.
General examination:
No pallor,icterus,cyanosis and clubbing.
There is no edema of feet.
Vitals: temperature:
Bp:150/70
Pulse rate:122/min.
spO2:85
Fixed neck deformity since 10years.
Systemic examination:
CVS examination-
S1&S2 sounds heard.
Respiratory:
Vesicular breath sounds.
BAE positive.
Abdomen:
Distened,no tenderness,no palpable masses,
Bowel sounds heard.
CNS:
Concious
No speech,not coherant.
Right. Left
Reflexes:
Biceps. 2+. 3+
Triceps. 2+. 2+
Supinator. -. -
Knee. 2+. 2+
Ankle. 2+. 2+
Investigations:
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