General medicine 2

 2023
Case scenerio.... 

Hi, Iam k. Sahalya, 3rd year BDS student. 
This is an online elog book to discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio. 

Case history :  A 50 years old male patient, resident of Mothkur,Telengana came to General medicine OPD on 2023.


 CHIEF COMPLIANT:
Patient complaince about No movement of both  left upper and lower limbs since 3 days 


HISTORY OF PRESENT ILLNESS:
Patient was apparantly asymptomatic 3 days back and then he noticed no movement in his left upper and lower limb and  associated with chest pain, shortness of breathing, difficulty in speaking. Immediately he was brought to hospital on 3days back accompanied by his wife and he was given iv injection which was not known to patient and there was relief in chest pain. 




Past history :
Patient gives a history of chest pain 15 yrs back for which he was diagnosed as tachycardia(hypertensive) and prescribed medication . Patient gives a history of asthma for that he is using salbutamol also gives a history of
Jaundice 10 days back for which he was admitted in hospital and discharged  3days back.

 Drug history:
Patient is under medication
Tab. Sacubitril-50mg
Tab. Frusemide-5ml
Tab. Salbutamal-2ml
Tab. Ecospirin-AV 75
Tropicamide and phenylephrine eye drops-5ml

Family history:
No relevant family history. 


Personal history: 
Mixed diet
No proper sleep
Good appetite
 Yellowish Micturation, no burning sensation while micturation. 
No Deleterious habit

General history:
Patient is conscious, cooperative. 
Patients is moderately built. 
 Gcs scale : 
E-4(spontaneously) 
V-3(inappropriate words) 
M-4(withdrawal of pain) 
T=11

Pallor seen
Icterus present
No signs of Cyanosis,Clubbing,Koilonychia,Lymphadenopathy and edema.

SYSTEMIC EXAMINATIONS:
Respiratory: BAE+,dyspnea 
                       Wheeze not seen
Reflexes: right upper limb+, left lower limb _
                 Right lower limb+, left lower limb_
No signs of paraesthesia. 
Eyes:Yellow sclera
Cranial nerves- no abnormality detected, no cervical spine injury
                      
Abdomen: 
Shape of abdomen: scaphoid
Tenderness : on left hand





provisional diagnosis:
Tachycardia, Jaundice

Questions:
What is the cause of tachycardia? 
How can I reduce risk of tachycardia?
What is the main cause of no movement of left upper and lower limb? 
Is there any relation between  jaundice and immobilization of left upper and lower limb? 

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