48/M WITH EQUINE GAIT PARAPARESIS 2 MONTHS HBV+
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings investigations and come up with diagnosis and treatment plan
UNIT 1
MEDICAL WARD
DOA:04/06/23
A 48 year old male farmer by occupation,resident of Nalgonda came to the opd with chief complaints of
WEAKNESS OF BOTH LOWER LIMBS SINCE 6MONTHS
BURNING SENSATION OF FEET SINCE 1 MONTH
HOPI::
Pateint was asymptomatic 6 months back then he developed weakness of both lower limbs which is insidious in onset and gradually progressive.
Associated with burning sensation of feet and pain in the calf muscle
Patient also complaint of losing footwear while walking
Patient also complaints of tingling sensation in both feet but can't appreciate it became burning sensation is more
Patient was able to walk on his own till I month back but since 1 month patient needs supply to walk
Visited local hospital 6 months back and using treatment since then
PAST HISTORY
No history of diabetes, thyroid,epilepsy,asthma,CAD CVA
PERSONEL HISTORY:
Diet:mixed
Sleep:regular
Appetite: Normal
Bowel and Bladder Movements : Regular
Addictions::He had a history of taking alcohol since 25 years and stopped one year back
Family history: Not significant
General examination::
Patient is conscious,cohorent , cooperative well known with time, place, person
He is well built and moderately nourish
Pallor present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: absent
Vitals::
Afebrile
PR- 94bpm
BP- 100/90mmHg
RR- 14cpm
CVS: s1,s2 heard ,no Murmurs,
RS:BAE+ ,no added sounds ,NVBS,
P/A: soft, non tender
CNS:
Tone. UL. LL
Rt. Normal normal
Lf. Normal. Normal
Power of right and left UL and LL is
5/5 and 4/5
Reflexes. B T. S. K. A. plantar
Lt: 2+. 2+. +. 3+. -.M
Rt: 2+. 2+. +. 3+. -. M
Provisional Daignosis: ? Chronic inflammatory Demyelinating polyneuropathy
Investigations::
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