GENERAL MEDICINE ELOG

August 17,2021

GM case

Shwetha Mummadi
Roll no: 87
3rd sem.

This is an online E log to describe and discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.

I have done this case elog under the guidance of Dr.Lakshman sir, Intern.


Case:



A 50 years old female patient ,Home maker by occupation came to casuality with complaints of 
Deviation of mouth to Right side on Saturday Evening lates on Monday.
 She noticed that she is  unable to close her Left Eye and also watering from that  eye.
Drooping of saliva from her mouth.




Chief compliants:
  • Deviation of mouth to Right side. 
  • Drooping of saliva from the mouth.
  • Can't close Left Eye and Watering of left eye.



HISTORY OF PRESENT ILLNESS:


- C/o Neck pain.
- No c/o Weakness of upper and lower limbs.
- No c/o blurring of vision.
- No c/o loss of taste.
- No c/o giddiness or fever.



HISTORY OF PAST ILLNESS :


2 Years back patient had same complaints
- Deviation of mouth to Right side and drooping of saliva for 1 week.
- H/o blackish discoloration of B/L lower limbs

4 days back-
C/o dry cough
C/o cold and 
C/o sore throat

Subsided now.

-Not a known case of  diabetes, asthma,CAD,TB,
- No Hypertension.
- Not undergone blood transfusions,past surgeries
- Not kept on hormones, antibiotics and chemo radiation.



PERSONAL HISTORY:


- Married and Home maker

  • Appetite - Normal
  • Bowels - Regular
  • Micturition - Normal
         • No known Allergies
         • Not an addict of Alcohol or drugs.



FAMILY HISTORY: 

Not required in this case.



ON PHYSICAL EXAMINATION -


VITALS:

•Temperature- afebrile
•Pulse rate -96/ min
• Respiration rate - 16/min
• BP -120 /90 mm/Hg
•Spo2 at room air- 97%
• GRBS - 123 mg%


General Examination:

•No pallor
•No cyanosis
•No Lymphadenopathy
•No icterus
•No clubbing 
•No oedema of feet


SYSTEMIC EXAMINATION:


 •CVS: S1, S2 heard, No murmurs. 
 •RS:  Position of trachea : Central 
 •BAE : +  
 •P/A : Soft, Non Tender, No palpable masses or swelling.


PROVISIONAL DIAGNOSIS:


UNILATERAL LMN Type of BELL'S PALSY



INVESTIGATIONS:

Fever chart 



T3,T4,TSH ESTIMATION




TREATMENT HISTORY:

 12-08-2021

TAB. prednisolone 40mg
TAB. Valcyclovia 1gm
TAB. Pantop 40mg
GRBS CHARTING 8th hrly
Bp/PR/ Spo2 charting 4th hrly
ILO charting

13-08-2021

 TAB.Prendnisolone 40 mg
 TAB.valcyclovia 1gm
 INJ.optinous 100 ml
 TAB. Pantop 40mg
 GRBS CHARTING 8th hrly
 Strict ILO charting

 14-08-2021

 TAB.Prendnisolone 40 mg
 TAB.valcyclovia 1gm
 INJ.optinous 100 ml
 TAB. Pantop 40mg
 GRBS CHARTING 8th hrly
 Strict ILO charting
 TAB.MUT

NOTE: 

She got discharged on 14-08-2021



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