General medicine case 2

General medicine case2

September 14, 2022

A 57 year male patpatient complaints of giddiness and swinging to right

September 14 ,2022



Hi,I am B.Arundathi 3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio. 


                   CASE SHEET 


Chief Complaints:

A 57 years old male patient auto driver by occupation resident of suryapet came to op.

.Hypertension with excessive sweating for 10days

.Giddiness, difficulty in walking, swinging to right.


HISTORY OF PRESENT ILLNESS:

He was asymptomatic 5days back and then developed pain and swelling of bilateral lateral malleolus for which he visited local RMP for which he received an injection followed by which he developed excessive sweating and the next day he developed excessive sweating and giddiness and difficulty in walking, associated with swinging to right,for which he went to local hospital and  CT was done and medications were given.Later,he perceived objects as two(diplopia)and it got resolved by its own after 30min.


HISTORY OF PAST ILLNESS:

Blood pressure @ presentation:170/100mmHg

No diabetes 

No Asthma 

No Tuberculosis 

No blood transfusion

No surgeries 


DRUG HISTORY:

No drug history


ALLERGY HISTORY:

No allergy history


PERSONAL HISTORY 

Apetite:normal

Bowel: regular

Micturition:normal

Diet: non-vegetarian 


HABITS:

Alcohol-chronic alcoholic for 20yrs and stopped  2yrs back

Tobacco:Beedi smoker for 22yrs

Beetal pan:no

Betel nut:no


PHYSICAL EXAMINATION 

Pallor:no

Cyanosis:no

Icterus:no

Lymphadenopathy:no

Clubbing of fingers/toes:no

Oedema of feet:no

Dehydration:no


VITALS:

Temperature:98.6c/f

Pulse rate:86/min

Respiration rate:16/min

Provisional diagnosis:
Actue cerebellar infart

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