Gm Case..

Case scenario...
Hi ,I am M.Sindhupriya 3rd bds student.This is an online elog book to discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio 

                  CASE HISTORY
Case sheet:
A 55 year old male ,came from gowraram to general medicine opd
Chief complaints:
Difficulty in lifting left upper limb & loss of speech no h/o mouth angle deviation
HISTORY OF PRESENT ILLNESS:
Patient was apparently Asymptomatic , But 10 days back difficulty in lifting left upper limb & loss of speech,then treatment at nalgonda hospital gradually recovered.
 Duration: 12 hours
Onset: sudden
Time of occurrence: work
Flaccid type of paralysis 
Weakness:upper limb 
Proximal: present
Distal: present
Lower limb weakness: absent
Weakness of Trunk : absent 
Weakness of Neck : absent
H/o Sensory loss :
Touch sensation:present
Pain sensation: present
Timbling sensation: present
H/o loss of consciousness: present
Vomiting: present
Diarrhea: present
Headache: present
Blurring of vision present
 Burning micturition: present
Loss taste sensation
PAST HISTORY:
A know case of diabetes mellitus since 5 years
A know case of hypertension since 10 days from the day of paralysis
No h/o previous surgeries
No h/o asthama, epilepsy, cardiovascular disease 
PERSONAL HISTORY:
Diet: mixed
Appetite: normal
Sleep: Adequate
No smoking
Alcohol Consumption: Occasionally
Bowel movements: Present
Bladder movement: absent
FAMILY HISTORY:
 Similar h/o present in his father
DRUG HISTORY:
Not significant
GENERAL EXAMINATION:
Patient was conscious
Coherent
Cooperative
Poorly built
Moderately nourished
Pallor present
Clubbing cyanosis: absent
SYSTEMIC EXAMINATION:
1.Cardiovascular system:
Cardiac sounds: S1, S2 heard
No thrills
No cardiac murmurs
2.Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular Normal
3.Abdomen:
Shape: distended
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
4.Central Nervous System:
Conscious
Speech: absent
Coherent higher motor function s intact
Biochemical Investigations:
Treatment:

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