A 65 yr old male with weakness in limbs bilaterally

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.


Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
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 a diagnosis and treatment plan.


Case scenario:

A 65 yr old male resident of Nalgonda came to the OPD with c/o weakness in upper and lower limbs since 10 days, neck pain since 10 days, unable to hold objects since 10 days. 

History of present illness:

Patient was apparently asymptomatic 10 days ago. He then gradually developed weakness in limbs which is more in the upper limbs comparatively. He had history of fever along with the neck pain. 

Past history:

Patient had complaints of giddiness 6 months ago. He went to the hospital and was diagnosed with diabetes. He was started on oral anti - diabetic agents(OHA’s) Metformin 500 mg. 

The patient developed  hyperpigmented lesions on consuming fish 6 months ago and had similar complaints 25 days ago. 

He was diagnosed with diabetes 6months ago.
He is not a k/c/o of hypertension,tuberculosis,asthma. 

Personal history: 
Diet: Mixed
Appetite: Normal
Sleep:Adequate
Bowel and bladder movements: Regular
Allergies:No
Addictions:No

FAMILY HISTORY:
No H/o Similar complaints in the family.

PHYSICAL EXAMINATION:
Patient is conscious, coherent and cooperative. 
Moderately built and moderately nourished.
Well oriented to time place and person.

Pallor present 
Bilateral oedema in lower limbs
No icterus 
No cyanosis 
No clubbing 
No lymphadenopathy

Hypopigmented patches on dorsal side of both hands.


VITALS 
Temperatures: afebrile
Pulse rate: 89bpm
BP: 110/80 mm Hg in right arm in supine position.


CNS EXAMINATION:
Reflexes:
Knee reflex: absent in left limb
Ankle reflex : absent in right and left limbs
Plantar reflex: decreased in left limb.

No meningeal signs are present. 

CVS EXAMINATION:
Cardiac sounds S1 S2 heard
No murmers heard 

 RESPIRATORY SYSTEM :
Normal vesicular breath sounds heard
Trachea: central
No wheeze
 
ABDOMEN EXAMINATION:
Shape of abdomen: scaphoid
No tenderness 
No palpable mass
Liver not palpable








Investigations :

ECG
CBP
CUE
RFT
LFT
Serology
X-ray spine


~> CBP:
Hb - 11.7g/dL
TLC - 9,500 cells/cu.mm
Platelet count - 3.72 lakhs/cu.mm

~> Serum electrolytes:
Na+ : 148mEq/L (136-145mEq/L)
K+ : 4.1 mEq/L 
Cl- : 101 mEq/L 


~> LFT:
Direct bilirubin: 0.26 mg/dL (normal values: 0-0.2)
Alkaline phosphate: 185 IU/L (56-119)

~> Serum creatinine: 1.2 mg/dl
~>Blood urea : 31 mg/dl


Comments

Post a Comment

Popular posts from this blog

75 yr old with sob and cough

Image
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. 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 a diagnosis and treatment plan. Case Discussion.  75 year old male, resident of Suryapet came to OPD with chief complaints of cough since 2 months and breathlessness since 1 month and Pedal edema since 15 days. History of presenting illness. Patient was apparently asymptomatic 2 years ago, later he developed SOB...
Read more

Internship Learning experience in medicine posting

Here, I have explained all the things that I've learnt and did in my General Medicine internship postings during 2023. Cases :   https://prathyushasingam.blogspot.com/2023/05/42m-calculous-cholecystitis.html http://prathyushasingam.blogspot.com/2023/05/55f-with-left-hemiparesis.html https://prathyushasingam.blogspot.com/2023/05/35m-with-pedal-edema-and-sob.html https://prathyushasingam.blogspot.com/2023/04/67f-with-sob-decreased-urine-output.html https://prathyushasingam.blogspot.com/2023/05/raju-ward-case.html   Procedures : - Inserted Ryle's tube under the guidance of  Dr. Vivek for an AMC case. - inserted Foley's catheter and also did the removal of Foley's catheter for different patients in ICU.  - Assisted 2 lumbar puncture procedures.  ICU/AMC duties : - Assisted 1 central line in ICU case and 1 central line for AMC case under the guidance of Dr. Venkat, Dr. Nithin.  - Assisted lumbar puncture for 2 ICU cases.  Ward duties : - guided my co-intern...
Read more