Clinical Logs

 CHIEF COMPLAINTS: A 32yr old gentleman came to the OPD with chief complaints of: B/L Lower limb weakness (Left > Right) B/L Lower limb pain HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 3 days backs. H/o heavy weight bearing. He developed Left lower limb pain which was insidious in onset, gradually progressive and dragging type No h/o trauma No swellings noted HISTORY OF PAST ILLNESS: N/K/C/O DM/HTN/Thyroid disorders TREATMENT HISTORY: Not significant PERSONAL HISTORY: Married Appetite: Normal Diet: Mixed Bowels: regular Micturition: Normal No known allergies Habits/Addictions: Regular alcohol and tobacco consumption FAMILY HISTORY: Not significant GENERAL EXAMINATION: No Pallor No Icterus No Cyanosis  No Koilonychyia No Clubbing No Lymphadenopathy No Edema VITALS: BP: 110/70 mmHg PR: 80 bpm RR:  16 cpm Temp: Afebrile SpO2: 96%  @ RA SYSTEMIC EXAMINATION : CVS: S1,S2 heard No murmurs No thrills Respiratory System: Position of trachea: Central Breath soun

A 70 year old female came with complaints of neck muscle stiffness and unable to speak. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 7 yrs back. Then she developed pain in right shoulder for which she was managed conservatively. 5 yrs ago, she developed weakness and giddiness and was diagnosed with HTN. Since 5 yrs, she developed pain in both lower limbs. PAST HISTORY: k/c/o HTN No history of DM. No history of TB. No history of Bronchial asthma. PERSONAL HISTORY: Diet: Mixed Appetite: Decreased Adequate sleep Bowel & bladder movements: Normal and Regular TREATMENT HISTORY: 1. TAB. ATENOLOL 25mg  2. TELMA-40  3. TAB. ACECLOPHENAC 4. TAB. PREDNISOLONE 5mg GENERAL EXAMINATION: Pt. is conscious Pallor is seen No icterus No cyanosis No clubbing No lymphadenopathy No pedal edema                                                     VITALS: Temp: Afebrile PR: 105 bpm BP: 130/80 mmHg  Respiratory rate: 22 cpm                                                        S