60F Tingling and Numbness

This is an a 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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 


A 60 year old female patient agricultural worker by occupation,resident of kodad came to general medicine department with C/o Tingling and numbness of both lower limbs from ankle to calf muscles since 1 year
       
HOPI
patient was apparently asymptomatic 10 months back,then she had tingling sensation and numbness of lower limbs from ankle to calf muscles which  was insidious in onset,gradually progressive and lost sensation of foot. 
She was taken to khammam private hospital with similar complaints,taken medication but not relieved
C/o Shortness of breath while walking few steps and stops for some time to take breath with no aggravating and relieving factors
Nocturia present
Polyphagia present
Polyuria absent
No c/o chest pain, palpitations, orthpnea and paroxysmal noturnal dysuria
No c/o burning micturition
No c/o fever,cough and cold

Past history
K/c/o diabetes since 30 years
K/c/o bronchial asthma since 30 years
K/c/o hypertension since 1 month
K/c/o CKD since 1 month
N/K/c/o epilepsy,TB

TREATMENT HISTORY
Drug history
Tab.Metformin 500mg three times a day for diabetes since 30 years
Levosalbutamol for bronchial asthma since 30 years and budesonide since 1 month
Tab.losartan  for hypertension since 1 month
Past surgical history
Tubectomised 30 years back
Hysterectomy  20 years back

PERSONAL HISTORY
Patient takes mixed diet
Appetite decreased
Regular bowel and bladder movements
Sleep disturbed due to tingling and burning sensation of feet
Addictions -  toddy drinker

FAMILY HISTORY
no significant family history 
ALLERGIC HISTORY
no allergies to any kind of drugs or food items
GENERAL EXAMINATION
Patient is conscious, coherent, and cooperative 
Moderately built and nourished
Pallor present

No icterus 
No cyanosis 
No clubbing
No lymphadenopathy




VITALS:

Temperature - Afebrile
Pulse Rate - 88 bpm
Respiratory Rate - 16cpm
Blood Pressure - 110/70mmHg
Sp02 - 99% at Room air
GRBS - 344 mg/dl

SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
S1 ,S2 heard,no murmurs,no thrills

RESPIRATORY SYSTEM
INSPECTION
Bilateral Air entry Present
Trachea- central 
Movements of Chest decreased on left side

Type of respiration- thoracoabdominal 

On percussion, all lung fields are resonant

On auscultation Normal vesicular Breath sounds are heard, and there are no added sounds

Per abdomen examination

Soft and non-tender

No organomegaly

No palpable masses

CNS examination

Normal

No focal neurological deficit 


INVESTIGATIONS 

PROVISIONAL DIAGNOSIS
DIABETES NEPHROPATHY WITH KNOWN CASE OF DIABETES,BRONCHIAL ASTHMA , HYPERTENSION AND CKD

TREATMENT

Nebulisation Duolin 6th hourly
                   Budesonide 12th hourly
Tab Losartan 50 mg po/oD
Tab metformin 500mg PO/BD
GRBS PROFILE
 


Comments

Post a Comment

Popular posts from this blog

FORMATIVE BIMONTHLY BLENDED LEARNING ASSIGNMENT.

Hi , this is G. Jagadeesh , 3rd semester student on online E-learning platform . These are pe er reviews of certain cases of deidentified data of some patients. Q-1 CASE-GASTROENTEROLOGY  https://vamsikrishnarollno16. blogspot.com The case is about the Obstructive jaundice . He is of 64 year old male . The presentation is very nice - appreciable The pictorial represention of Icterus sign in the sclera is excellent. CASE - CNS https://87tharunkumar. blogspot.com/ The case is related to Demyelinating lesion secondary to Hypertension . case presentations is very good with side headings Every Investigation reports are mentioned clearly and with appropriate Graphs and photos Which actually gives a completion to the blog and is satisfactory . Treatment is mentioned clearly with all drugs such as their routes of administrations and perfect dosage.  patient progress report daily is not mentioned. CASE-HEMATOLOGY https://mahithguduri63. blogspot.com/ It is case of pancytopenia of 70 year old ma
Read more

70M with SOB and cough

Image
Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning   This is an 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 The patient/ attender was informed the purpose of the information being acquired. An infor
Read more

54M with fever and SOB

Image
Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning   This is an 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. 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 The patient/ attender was informed the purpose of the information being acquired. An informe
Read more