This is an E log book to discuss our patient's de-identified health data shared after taking his 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 those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed.

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

Case Discussion :

My patient is a 70 years old male who is a resident of miryalaguda , agriculture labour by occupation came to OPD 


Chief complaints:


Tingling and numbness of upper limb and lower limb since one year

  


History of presenting illness:


Patient was apparently asymptomatic one year back then developed tingling and numbness sensation of upper limb and lower limb which is insidious in onset and gradually progressive.

-No H/O burning micturition , pains in the abdomen , loose stools

-No H/O shortness of breath, chest pain and palpitations .

Daily Routine: 


Patient wakes up at 5am , drinks one litre water and go for a walk of 2km. Takes breakfast and take care of some house hold works and take lunch around 12:30 and takes a rest till evening and take dinner around 7 and sleeps by 10pm.


Past History

-Not a  known case of thyroid disorder, epilepsy,      TB.

-known h/o hypertension since 1 year and on amlong 5mg

-known case of type 2 diabetes mellitus and on medication of metformin 500mg and glimiprimide 1mg







Personal History:



Diet - mixed
Appetite - Normal
Bowel and bladder - regular 
Sleep - adequate 
No addictions

Family History:
 No significant family history 

General Examination:
 
Pallor - present
Icterus-ab
Cyanosis- ab
Clubbing - ab
Lymphadenopathy- ab
Edema- ab



Vitals : 
Temp- Afebrile
PR - 86 b/m
RR - 17 c/m
Bp- 130/80

Systemic examination: 

Patient is Conscious, coherent and co-operative with time, place and person

CNS Examination:
 
Higher mental Function
=>Speech : Normal
=>Memory  : Intact
=>Appearance : well kept

Cranial Nerves:
 

CN 1 : smell sense RIGHT       LEFT 
                                +.               + 
CN 2 : visual acuity normal     Normal 
CN 3 4  6 : extra ocular movement : full 
                   Direct light reflex present 
                   Consensual light reflex present 
                    Ptosis absent 
                     Accommodation reflex present 
CN 5 :        Sensory : over face ,buccal mucosa : normal 
                   Motor: masseter ,temporalis : normal 
                    Reflexes :corneal : normal
                                 Conjunctival : normal 
CN7 :     Motor : nasolabial fold : present 
            
                Reflexes: corneal conjunctival present 
 CN 8:    Rinnes  normal
                Webers  normal 
             Nystagmus : absent     
          
CN 9 and 10 : uulva movemts normal 

Motor system:

BULK: Inspection : normal
             Palpation : normal
MID ARM CIRCUMFERENCE: RIGHT -24cms    LEFT-23cms
                                                   
TONE: both upper limbs - normal
           both lower limbs- normal
POWER:          
           SHOULDER
flexion  :         5/5    5/5  
                        5/5.    5/5 

Extension        5/5.  5/5
Abduction          5/5.  5/5
Adduction         5/5.     5/5
Internal rotation 5/5.   /5
External rotation    5/5.   5/5

Elbow:

Flexion.     5/5.   5/5
Extension: 5/5.   5/5

Wrist:
Flexion:5/5.   5/5 
Extension: 5/5.   5/5
Abduction : 5/5.   5/5
adduction:5/5.   5/5

HIP
Flexion:5/5.    5/5 

Extension.  5/5.   5/5

Abduction:5/5.   5/5

Adduction 5/5.    5/5

Internal rotation:5/5.    5/5

External rotation.  5/5.    5/5


Knee 

Flexion 5/5.    5/5

Extension.   5/5.   5/5 

Ankle.  5/5.     5/5

Plantarflexion:.   5/5.    5/5

Dorsiflexion.     5/5.  5/5


Toe.   5/5  5/5

Reflexes :
SUPERFICIAL:
 Plantar -flexion
Abdominal reflexes -normal



DEEP TENDON REFLEXES :
                Rt      Lft 
Biceps :  + 2      +2
Triceps:   +2     +2
Supinator: +2   +2
Knee jerk: +2  +2
Ankle jerk: +2    +2 

SENSORY SYSTEM : 
Posterior column:
 fine touch  - normal 
  Vibration  -  normal
 
SPINO THALAMIC : 
Pain : normal
Temperature: normal 

CEREBELLAR SIGNS : 
Dysdiadokokinesia-absent
Nystagmus-absent
Finger nose test :  normal 
Heel knee test : normal
MENINGEAL SIGNS 
neck stiffnesses. 




Per abdomen: 
soft on palpation, bowel sounds heard,    no distention present.





Respiratory system: 
no wheeze heard, no crepitus heard, normal vesicular breath sounds heard

CVS: 

Inspection : 
Shape of chest- elliptical 
No engorged veins, scars, visible pulsations

Palpation :
Apex beat can be palpable in 5th inter costal space

Auscultation : 
S1,S2 are heard
no murmurs

Provisional Diagnosis :
 Diabetic neuropathy

Investigations:





















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