General Medicine Case Discussion

GENERAL MEDICINE E-BLOG



Hi, I am Krishna Swarali V of 5th semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.

The patient’s consent was taken verbally prior to history taking and examination of his/her condition.

A 70 year old male carpenter from Buddharam came to the general medicine OPD with the chief complaints of shaking hands and memory loss since 1 year

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 1 year ago

Then loss of orientation and tremors started abruptly. Tremors were resting tremors present throughout the day associated with tingling sensation and were relieved during sleep.

They were associated with 2 episodes of headache per week which was localised to bitemporal region and radiates to neck bilaterally and not associated with nausea, vomiting, photophobia and phonophobia.

Tremors were localised to right upper limb from elbow to tip of hands and bilateral lower limbs from knee joint to soles.

HISTORY OF PAST ILLNESS 

Patient was known case of hypertension

He had an episode of generalised seizures 1 year ago for which he received treatment and the tremors slightly reduced.

No history of other comorbidities.

FAMILY HISTORY 

Mother was a known case of hypertension 
No other significant family history.

PERSONAL HISTORY 

Loss of appetite since 1 year
Constipated bowel relieved on medication 
Normal bladder
Mixed diet
Inadequate sleep 
Alcoholic - 45 ml per day since 20 years
Smoking history- beedi 55 pack years

DRUG HISTORY 

History of atenolol and amlodipine since 20 years
History of donepezil since 1 year

GENERAL EXAMINATION 

Physical examination 
Patient was conscious coherent and cooperative 
No pallor
No icterus 
No clubbing 
No cyanosis 
No lymphadenopathy 
No pedal edema 

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