General medicine e-log 5





 Hi, I’m A Naga pravallika 6th Sem medical student.This is an online e-log book to discuss our patient health data.This also reflects my patient centered online learning portfolio 


 A 60 year old male patient came with cheif complaints of shivering of right arm and forearm since 2years 

  HOPI -
                Patient was apparently asymptomatic 2years back. He then developed shivering of right hand and forearm 
 Insidious onset and gradually progressive. Initially localised to fingers and later radiated to right arm 
C/O- numbness , tingling 
        Pain & Tingling in the right thigh 
        Shivering is present throughout the day intensity increases and decreases.


PAST HISTORY -
                            No history of trauma or injury in the past 
         N/ K/C/O- diabetes ,BP, TB ,epilepsy.

FAMILY HISTORY -
                                   No significant family history 

PERSONAL HISTORY -
                      Appetite - normal      
                       Sleep-adequate 
                        Diet-mixed 
                         Bowel&bladder - normal 
                        Micturition - Normal 
                        Alcohol - occasionally since 25 years 
                                       Stopped 3-4 years back 
                         Smoking -since 25 years, stopped 
                                             6years back 
GENERAL EXAMINATION- 
                                    Patient was conscious, coherent and well oriented with time ,place and person.

                          No pallor 
                          No icterus 
                          No cyanosis 
                          No lymphadenopathy 
                          No edema 
VITALS -  BP -110/80 mm hg 
                   Pulse - 84bpm
                   Temperature- Afebrile 
                    Respiratory rate- 16/min








      SYSTEMIC EXAMINATION

Cardiovascular system 

No thrills 
No cardiac murmurs
Cardiac sounds: S1 and S2 heard


Respiratory system

dyspnea absent 
No wheezing
No Vesicular breath sounds .
Position of trachea - central


Abdomen

Abdomen is scaphoid
No tenderness
No Palpable mass 
Bowel sounds anew present 
No bruits
No free fluids


Central nervous system

Patient was conscious and coherent well oriented to time, space and person

Speech is normal 
Cranial nerves normal 
Motor system normal 
Sensory system normal 
Glasgow scale normal 


REFLEXES



                                      Right.                       Left 



Biceps                             ++                           ++ 



Triceps                            ++                            ++



Supinator                        ++                             ++



Knee                                ++                             ++



Ankle                             ++                               ++



CEREBELLAR SIGNS 

finger nose in coordination 

Knee heal in coordination 
GAIT 
 Notmal 
                                                                                                  

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