A 35yr old male with loss of sensation in both the lower limbs
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.
Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solveb 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 inputs on the comment box is welcome.
A 35 year old male with chief complaints of loss of sensation in both limbs below knee and palms since 6 months.
History of presenting illness:
Patient was apparently asymptomatic 4 years back. He then developed stomach pain where he got admitted to hospital when he got diagnosed as having high blood sugar as an incidental finding and started on oral hypoglycemic drugs then since 6 months he stopped taking medications for
diabetes from then he develop polyphagia, polydypsia
increased frequency of urination present
delayed wound healing present weight loss present
Tingling sensation of both upper limbs( palms)& lower limbs present
Loss of sensation present
Numbness present
No h/o headache ,vomitings
Daily routine
He wakes up in the morning at 6 am
Has his breakfast (rice)by 8am
Goes to work at 9am
Has his lunch at 1pm
He goes back home by 8pm
Patient has been drinking alcohol since he was 15 years old.He starts his day by drinking alcohol.
He also chews tobacco and gutka
He also had alcohol withdrawal symptoms
Past history:
K/C/o DM since 4 years -Stopped Medication since 6 months due to financial constraints
Not a k/C/O HTN,TB, CAD, Asthma, epilepsy
Personal history:
Diet: mixed
Sleep:adequate
Apetite: decreased
Bowel and bladder: increased frequency
Addictions: alcohol since he was 15 years old
GENERAL EXAMINATION:
Patient is conscious,coherent and cooperative, moderately built and moderately nourished.
Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy: absent
Pedal edema: absent
VITALS:
Temperature: afebrile
Pulse: 86bpm
Blood pressure:120/80mm Hg
Respiratory rate: 18cpm
SYSTEMIC EXAMINATION:
CVS: S1 and S2 are heard
RS: trachea central bilateral air entry present,NVBS,
Abdomen: soft and non tender,no organomegaly
CNS: higher mental functions intact
Right. Left
Bulk: Normal Normal
Tone:
Upperlimb. Normal. Normal
Lowerlimb. Normal Normal
Reflexes: biceps. +. +
Triceps. +. +
Supinator. +. +
Knee. +. +
Ankle. + +
Plantar Flexion. Mute
Sensory examination
Spinothalamic tract
Crude touch Right Left
Upper limb Normal Normal
Lower limb Decreased Decreased
Pain
Upper limb Normal Normal
Lower limb Decreased Decreased
Temperature
Upper limb Normal Normal
Lower limb Decreased. Decreased
Posterior column
Fine touch
Upper limb Normal Normal
Lower limb Decreased. Decreased
Vibrations. Decreased. Decreased in lower limbs
Cortical
Tactile localisation
Upper limb Normal Normal
Lower limb Decreased. Decreased
Stereognos
Upper limb Normal Normal
meningeal signs absent
Provisional diagnosis:
Comments
Post a Comment