43 year old patient , constructor by occupation came to casualty..

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43 year old male , constructor by occupation came to casualty with the 

C/O - weakness of right upper and lower limb in the morning 

Slight Deviation of mouth towards left side.

HOPI-

A 43 old male patient construction worker by occupation , was apparently asymptomatic 2 days back and then developed 2-3 episodes of vomitings, food particles as content and non blood stained and asymptomatic till morning 8:00 am and 

then developed weakness of right upper and lower limb and mild deviation of mouth towards left. 

Patient also experienced Headache , blurring of vision and giddiness.

Daily routine- patient generally wakes up at 6:00am every morning 

HISTORY OF PAST ILLNESS-

H/o trauma one month back 

Injury to upper right limb resulted in pain and Swelling , subsided on medications.

No h/o DM,

Hypertension 

Asthma 

TB

Cardiac problems

Epilepsy

PERSONAL HISTORY-

Marital status- married

Diet:- mixed

Appetite-  normal appetite 

Bowel and bladder movements - Regular

Micturition- normal

Sleep :- adequate 

Addictions:-patient has a habit of chewing gutka 4 years ago.

Smoking - patient smokes 2 packets of beedi per day.

H/o smoking since 15 yrs

H/o Alcohol - since 15 yrs

Patient drinks daily

Drug addiction:- no

Allergies :- no h/o allergies

FAMILY HISTORY-

No relevent family history..

GENERAL EXAMINATION -

Patient was conscious, non coherent,moderately fit, moderately nourished and Cooperative, and examined in a well lit room.

No Pallor, 

No Icterus,

No Cyanosis,

No Clubbing,

No oedema (pedal)

No Lymphadenopathy

Vitals

Temp :- 98.1F

PR:- 89bpm

BP: 120/90mmHg

SpO2: 98% at RA

RR:- 20 cpm

SYSTEMIC EXAMINATION-

CVS - no thrills 

           No murmurs

           S1 S2 +

Respiratory- breath sounds - vesicular

                      No dyspnea

                      No wheeze

Position of trachea- central

Abdomen - shape - scaphoid

                 No tenderness

                 No palpable mass

                 No free fluid

Liver and spleen - not palpable