A 60 year old came with chief complaints of left temporal vision loss

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SRI CHANDANA 

Roll no: 98

8th semester 

Nov 08 2023

GENERAL MEDICINE 

COMPLAINTS

Patient came with chief complaints of right temporal visual loss since 20 days

HOPI

Patient was apparently asymptomatic 20 days back then he developed dizziness, which was sudden onset,non progressive associated with loss of consciousness followed by vomiting,non bilious ,non blood tinged.

No H/O deviation of mouth, loose stools,incontinence,fever,

On the day of incident:

He was going to his work then his right leg suddenly started shivering and dizziness .After around 20 mins he lost his right temporal vision.

PAST HISTORY 
K|c/o HTN Since 2months on medication ( Amlodipine 5mg)

H/o trauma to left eye 30 years back, followed by complete loss of vision (in Left eye).

Not a k/c/o DM, TB, epilepsy,thyroid disorders

Daily routine:

Patient wakes up at 6 AM then does his morning activities,drinks tea at7:30 am , breakfast (rice, dal) at 10 am, goes to work in farm and comes back at 1pm and does lunch ( rice,sambar, curry) and have tea and snack at 5pm , watches tv , dinner at 9 pm and sleeps around 10 pm

FAMILY HISTORY :

Not signigicant

PERSONAL HISTORY:

Diet- vegetarian since 20 days

Appetite - normal

Sleep -disturbed since 20 days

Bowel and bladder -regular 

Addictions- alcohol since 20 years now stopped since 20 days

GENERAL EXAMINATION:- 

-Patient is conscious, cooperative, with slurred speech 

Well oriented to time, place and person

-moderately built and well nourished 

Pallor - absent

Icterus - absent 

Clubbing - absent 

Cyanosis - absent 

Lymphadenopathy- absent 

Edema - absent 

VITALS: 

Temp:97.8°F

B.P:160/100 mmhg

P.R:82 bpm

R.R: 18 cpm

SYSTEMIC EXAMINATION:

CNS EXAMINATION:

Patient is concious,alert,co operative

HIGHER MENTAL FUNCTIONS 

He is right handed

Level of conciousness: conscious

Speech: normal

Intelligence:can do calculations 

No signs of meningitis

CRANIAL NERVES- normal function

MOTOR FUNCTION

                           Rt.                  Lt

Tone: UL.          N.                    N

           LL.          N.                    N

Power UL.        5/5.                 5/5

            LL.         5/5.                5/5

Reflex

   Biceps.          +2.                 +2                     

Triceps.            +2.                  +2

Supinator.         +2.                 +2  

Knee.                 +2.                 +2  

Ankle.                +2.                 +2  

Plantar.              Mute               Mute

CARDIOVASCULAR SYSTEM:

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

S1,S2 are heard

no murmurs

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

bilateral air entry present. Normal vesicular breath sounds.

Left eye picture due to trauma 20 yrs back

 

                     

Provisional diagnosis:

Cerebrovascular stroke?