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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::







Treatment:

1. Inj OPTINEURON 1 amp 100ml NS/IV/BD

2. Tab pregabalin 75mg po/hs

3. Tab ecosprin AV 75/10 po/Hs

4. Tab Pan 40mg PO/

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