GM - 05

March 06 2023
Case 05

Hi , I am V.Shivani 3rd year dental student .This is online elog book to discuss our patient health data after taking her consent. This also reflects my patient centered online learning portfolio.

CASE SHEET: A 70 year old male patient came with a chief complaint of headache and slurred speech.

CHIEF COMPLAINT: 
Headache on left side from 15 days
Difficulty to speak and slurred speech from 15 days
Intermittent cough with sputum from 1 week

HISTORY OF PRESENT ILLNESS:
Headache - Insidious unilateral headache on left side from 15 days ,the pain is radiating downwards to neck , dragging type of pain.
Slurred speech - He had difficulty in speaking from 15 days, decreased fluency and intensity of speech.
Cough - It is associated with thin sputum , intermittent and no diurnal variation .
He is not associated with fever,cold ,nausea.

PAST ILLNESS:
No hypertension
No Diabetes
No TB
No Asthma

FAMILY HISTORY:
NIL

PERSONAL HISTORY:
Diet - Mixed
Appetite - Normal
Sleep - Normal
Bowel and bladder - Normal
Addictions - Bidi ( one packet a day)
                      Alcohol
                      Toddy from 7 years

GENERAL EXAMINATION:
Built - Well built
Nourishment - well nourished
Consciousness - In conscious
Pallor - No pallor
Icterus - No
Cyanosis - No
Clubbing - No
Edema - No 
Lymphedenopathy - No

PROVISIONAL DIAGNOSIS:

Q/A
1.What might be the diagnosis?
2. Are there any chances for migraine as the headache is unilateral ?
3. Does his addictions play any role in aggrevating the conditions?


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