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 

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