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A 60 year old came with chief complaints of left temporal vision loss

GM e log

Nov,08 2023
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 and your valuable inputs on the comment box is welcome.
IMMANI AASRITHA

Roll no.49

8th semester

Nov 08, 2023

GENERAL MEDICINE

COMPLAINTS


Patient came with chief complaints of right temporal visual loss since 20 days


HOPI

Patient was apparently asymptomatic 20 days back then he developed dizziness, which was sudden onset,non progressive associated with loss of consciousness followed by vomiting,non bilious ,non blood tinged.

No H/O deviation of mouth, loose stools,incontinence,fever,


On the day of incident:

He was going to his work then his right leg suddenly started shivering and dizziness .After around 20 mins he lost his right temporal vision.

PAST HISTORY 
K|c/o HTN Since 2months on medication ( Amlodipine 5mg)

H/o trauma to left eye 30 years back, followed by complete loss of vision (in Left eye).

Not a k/c/o DM, TB, epilepsy,thyroid disorders


Daily routine:

Patient wakes up at 6 AM then does his morning activities,drinks tea at7:30 am , breakfast (rice, dal) at 10 am, goes to work in farm and comes back at 1pm and does lunch ( rice,sambar, curry) and have tea and snack at 5pm , watches tv , dinner at 9 pm and sleeps around 10 pm


FAMILY HISTORY :

Not signigicant


PERSONAL HISTORY:

Diet- vegetarian since 20 days

Appetite - normal

Sleep -disturbed since 20 days

Bowel and bladder -regular 

Addictions- alcohol since 20 years now stopped since 20 days


GENERAL EXAMINATION:- 

-Patient is conscious, cooperative, with slurred speech 

Well oriented to time, place and person

-moderately built and well nourished 


Pallor - absent

Icterus - absent 

Clubbing - absent 

Cyanosis - absent 

Lymphadenopathy- absent 

Edema - absent 

VITALS: 

Temp:97.8°F

B.P:160/100 mmhg

P.R:82 bpm

R.R: 18 cpm


SYSTEMIC EXAMINATION:


CNS EXAMINATION:

Patient is concious,alert,co operative


HIGHER MENTAL FUNCTIONS 

He is right handed

Level of conciousness: conscious

Speech: normal

Intelligence:can do calculations 

No signs of meningitis

CRANIAL NERVES- normal function

MOTOR FUNCTION

                           Rt.                  Lt

Tone: UL.          N.                    N

           LL.          N.                    N

Power UL.        5/5.                 5/5

            LL.         5/5.                5/5

Reflex

   Biceps.          +2.                 +2                     

Triceps.            +2.                  +2

Supinator.         +2.                 +2  

Knee.                 +2.                 +2  

Ankle.                +2.                 +2  

Plantar.              Mute               Mute



CARDIOVASCULAR SYSTEM:


Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

S1,S2 are heard

no murmurs


RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

bilateral air entry present. Normal vesicular breath sounds.


Left eye picture due to trauma 20 yrs back

 









Provisional diagnosis:

Cerebrovascular stroke?




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