Thursday, February 18, 2016

A 60 years old woman with right side of body weakness since 5 months

This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here early winter 2015 after collecting informed patient consent (form downloadable here) by LNMCH research assistant and patient-information-communication-executive for a discussion initiated by patient's primary care physician in-charge: 

Patient history :
C/O:
                Rt. Side of body weakness X 5 months
                Cough & Breathlessness X 15 days
                Abdominal pain & constipation,
                Slurring of speech X 5 days
                Truncal obesity X 5 months

H/O:
                Rt. Side hemiparesis suddenly 5 months back
                Recorded in 3 days (improved now, but still weakness+, Difficulty in speaking)
               
                HTN, DM (but not taking any medicine)


No H/O: of any type of allergy

Patient O/E images :


Patient latest treatment & doctor's notes images :



Investigation & report images :



 

Radiological images :













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