40 F paralysis in left upper and lower limb since 2 years, cough since four days

 Hi, I am Greeshma , 6th Sem Medical Student.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. 

CHIEF COMPLAINT

A 40 year old female patient cane to the opd with chief complaints of paralysis in left upper and lower limbs since 2 years and Bilateral blurred vision since 2 ywars and Cough since 4 days

HOPI

The patient was apparently asymptomatic 2 years ago then she devloped paralysis in left upper and lower limbs which was sudden in onset associated with blurred vision.She then developed cough 4 days ago which was not associated with sputum.

No complaints of headache

No complaints of dizziness 

No sinusitis 

No h/o loss of consciousness 

No complaints of chest pain, palpitations, SOB

No complaints of pain abdomen, vomitings, loose stools, burning micturition

PAST HISTORY 

patient is k/c/o HTN since 2 years

N/k/c/o DM, bronchial asthma, epilepsy, Tb, thyroid disorders

FAMILY HISTORY

Parients father is a k/c/o HTN and Paralysis

PERSONAL HISTORY 

Married

Farmer by occupation 

mixed diet

Normal appetite 

Adequate sleep

Bladder and bowel movements are normal

No allergies 

GENERAL EXAMINATION 

I have examined the patient after taking prior consent and informing the patient in the presence of a attendant. The examination was done in both supine and sitting position in a well lit room. 

The patient was concious, coherent and cooperative, well oriented to time, place and person

No pallor

No icterus

No cyanosis

No clubbing of fingers

No lymphadenopathy 

No pedal edema

No malnutrition 

No dehydration 

VITALS

temperature: afebrile

BP: 180/100 mmHg

Pulse: 82 beats/min

Respiratory rate: 16/min

SYSTEMIC EXAMINATION

CNS

Fully consious and alert

Speech - normal

No neck stiffness

No kernings sign

Cranial nerves - normal

Motor system - normal

Sensory system- normal

Glasgow scale- 15/15

REFLEXES

  Right -  biceps: +2    Triceps: +2

  Left -  biceps: +2      Triceps: +2

CEREBELLAR SIGNS

Finger-nose in coordination- NO

Knee- heel in coordination- NO

GAIT - hemiplegic

Musculoskeletal system - normal

Skin - normal

Examination of breast - normal

Examination of ENT - normal

Examination of teeth and oral cavity - normal

Examination of head and neck - normal