GENERAL MEDICINE E-BLOG
Hi, I am M. Harini of 3rd 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
