GENERAL MEDICINE

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 

1. COMPLAINTS AND DURATION

*p atient complaints  of Tingling and numbness I week of both UL And LL

 *Generalised weakness and body pains. I -week.

* decreased Tactile of LL. I-month

2. HISTORY OF PRESENT ILLNESS 

patient was apparantly assymptomentomatic I week back, and later he developed. Tingling and numbensof ULG LL, which is insidious in onset, and also complaints of decreased sensation in Lower limb

3. HISTORY OF PAST ILLNESS ;

*K/c/o DM..: • 3 years; (on medication LinagliptinBiphasic isophane 5mg) Stopped injection, I week back 

*Klclo HTN & On medicath Telmisartan(3years)

*K/c/oHypothyroidism : 3yrs Gou ・Thyroncm 25mcg. past history of kidney infection and treated for that and with sodium bicarbonate 1000mg now.

*H/o  using Febuxost at 40mg and Calcitrol.

PERSONAL HISTORY 

Married

Occupation:farmer (Stopped 3yrs back)

Appetite:decreased 1yr back

Diet:mixed 

Bowel and bladder:regular

No known allergies

Alcohol history

-stopped 3yrs back

FAMILY HISTORY 

Not significant 

PHYSICAL EXAMINATION 

No pallor,icterus,cyanosis,clubbing,lymphadenopathy, oedema

Temperature:101F

PR:108bpm

BP:100/70mmhg

RR:28cpm

Spo2:98%

GRBS:458g/dlat 12/4/22

SYSTEMIC EXAMINATION 

CARDIO VASCULAR SYSTEM: 

Thrills : no

Cardiac sounds : s1 and s2 are normal.

Cardiac murmurs : no 

RESPIRATORY SYSTEM: 

Dysponea : no

wheeze :no

Position of trachea : central

Breathing sound : vesicular

ABDOMINAL : 

Shape of abdomin ; scaphoid 

Tenderness : no

Free fluid ; no

Bruits : no

Bowel sounds ; no

CENTRAL NERVOUS SYSTEM 

Level of consciousness : conscious   alert 

Speech coherent and cooperative 

INVESTIGATIONS