General Medicine Case Study

Divya.B
Roll no:23


This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's 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 protfolio and your valuable inputs on comment box is welcome


A   58  year old male resident of suryapet came to the OPD with cheif complaints of pain in the right lower limb since 3 months and tingling sensation in the hands since 3 months.
 History of present illnesses:
    He was apparently asymptomatic 3 months back and then he developed pain in the lower limbs which was insidious in onset gradually progressive non radiating type. Pain aggravated on walking and relieved by rest 
 Pain is not associated with fever,chest pain,cough.
No H/o sweating, palpitations, orthoapnea 
No H/o burning micturition, decreased or increased urine output,loose stools,nausea, vomiting.


Past History:
History of trauma 3 months back .
History of Poliomyelitis since childhood.
No history of Diabetes, Hypertension, Asthma, Tuberculosis, Epilepsy.

Personal History:
Diet : mixed
Apettite: normal
Sleep: adequate
Bowel and bladder movements: regular 
Addictions: no addictions.
Family History:
His mother is hypertensive and diabetic.
General Physical examination
Patient is concious, coherent and cooperative and we'll oriented to time and place.
Vitals
 Temp: afebrile 
Bp: 
PR:72/min
RR:

No pallor
No icterus
No cyanosis
No clubbing
No pedal odema
No lymphadenopathy
 Systemic Examination
CVS:S1,S2 heard and no murmurs.
RESPIRATORY SYSTEM:B/L air entry present. Normal vesicular breath sounds heard.
PER ABDOMEN: 
Shape: ovoid
No tenderness
No organomegaly
No palpable abdominal mass
Bowel sounds heard.
CNS:

Sensory Examination
Pain sensation: present.
Touch
Fine touch and crude touch intact.
Pressure sensation present 
Vibration sense present 
Position sense -intact
Proprioception-intact
Rombergs test: negative 
Stereognosis: present 

 Motor system examination 
Bulk: normal(moderately built)
Tone: normal
Power:grade 5
Reflexes: are present.
                            Right.              Left.
Biceps                  2+.                    2+
Triceps                 2+                     2+
Supinator             2+                     2+
Knee jerk.             4+.                   4+    
Superficial 
reflexes
Cerebellar function
Speech -slurred
Gait- abnormal
Tremors present 
Finger nose test- normal
Dysdiadokinesia- normal
Knee heel test-normal
Nystagmus- absent

Provisional Diagnosis:

Comments

Post a Comment

Popular posts from this blog

camp case 4/5/2024.

Image
Camp case 80 yr old male  CHEIF COMPLAINTS: Came with c/o giddiness since 15 days. HOPI: Pt was apparently asymptomatic 15 days back and then had giddiness which was  episodic daily once ,mrng before lunch a/w blurring of vision during that episode and relieves after taking food. H/o tingling and numbness of lower limbs since 10 yrs extending from tip of toes to shin of tibia  H/o burning sensation of feet since 5 yrs  H/o chest pain since 4 days , pricking type ,on and off ,no precipitating factors H/o loose stools for one day which was one week ago and subsided on medication. No h/o polyuria polydypsia  No h/o decreased urine,output burning micturition  No h/o fever,pedal edema ,facial puffiness  No h/o constipation, No h/o similar complaints at night times No h/o sob , palpitations  PAST HISTORY  K/c/o Htn on tab telma am -40/5 K/c/o dm on INJ MIXTARD 20UBBF ,15U BD  K/C/O CKD SINCE 13 yrs  K/C/O HFPEF 2° to CAD since 1 month  H/O stable angina 1 month ago  No other comorbidities  P
Read more

23,Divya.B

 General Medicine blended assessment. Name:B.Divya Roll no: 23 Batch:2019(3rd semester). Question 1) Pulmonology : Review:- https://yrahul190.blogspot.com/?m=1 Case1:  https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html        The case was diagnosed as COPD associated with right heart failure and bronchiectasis.The patient is presented with shortness of breath, generalized weakness, pulmonary odema.In this case due to obstructive lung disorder,the workload on right heart leading to right heart failure. All the examination was done thoroughly and with proper investigations. This is very good presentation with all the images required for proper diagnosis and the treatment of all symptoms was also given properly. Neurology Review:-https://157siddhanth.blogspot.com/ Case2:https://143vibhahegde.blogspot.com/2021/05/wernickes-encephalopathy.html       The case was diagnosed as wernickes encephalopathy secondary to chronic alcohol dependence along w
Read more

General Medicine case study .

Image
B.Divya 5th sem Roll no 23 A male pt aged 50yrs a resident of Miryalguda  farmer by occupation was brought  to OPD by his son in law. Cheif complaints           Shortness of breath            Burning micturition           Headache            Throat pain  History of present illness   H/o shortness of breath since 1 yr H/o headache since 20days( occipital region) H/o neck pain since 1 yr. H/o throat pain since 4days(pricking type) History of past illness No H/o DM,Tb, Epilepsy,CKD, cardiovascular accidents. Cerebrovascular accident 25 yrs back. H/o previous medication (joint pains, headache,neck pain, shortness of breath) No H/o previous hospitalization. Family History His mother has Sob Personal History Married Occupation-farmer Appetite-normal Diet-mixed Sleeping habits:He has sleep alterations due to painsand discomfort. Bowel- regular Micturition- burning No H/o allergy Addictions- he smokes but stopped 2 yrs back.He smokes 4-5 cigerettes per day.He smoked for 40 yrs. Physical examin
Read more