I've 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 plan.
Following is the view of my case:
CHIEF COMPLAINTS:
Patient came with the complaints of weakness of both lower limbs since 1 week
Complaints of tingling sensation of both the lower limbs and both the upper limbs since 1 week
HOPI:
Patient was apparently asymptomatic 1 week back, then he developed pain in both the lower limbs which is insidious in onset, gradually progressive, squeezing type which is associated with weakness of both lower limbs since 1 week.
Pain and weakness of lower limbs started in feet and gradually progressed to whole upper limbs.
No complaints of fever, pain abdomen, neck pain, back pain.
5 years ago, he had similar complaints and relieved on medication without any hospital admission.
No complaints of urethritis, conjunctivitis, gastroenteritis.
Patient daily routine -
The patient eats non veg once in a week mainly on Sundays
7am- Wakes up
10am- Eats breakfast (Rice with curry)
After breakfast he used to go for labour work, but he stopped going to work 1 month back as he was searching for another job.
Now he reads newspaper, uses phone.
2pm- Eats lunch (rice with curry)
After lunch he used to go for labour work, but he stopped going to work 1 month back as he was searching for another job.
9pm- Eats dinner(rice with curry)
11pm- Sleeps
9 months ago he hadh a history of psychiatric illness (? Schizophrenia) and is on regular follow up and medication of Risperidone+ Trihexyphenadyl. Stopped medication 1 week ago( non compliance to medications)
Since 1 week, the patient was unable to wear slippers and walk. He is able to lift hands up and eat by self.
He was unable to squat down and stand.
PERSONAL HISTORY:
The patient works in Heritage as a mechanic, stopped 6 months ago and now working as a daily wage labourer.
Diet - mixed
Appetite- Decreased since 1 week
Bowel and bladder movements regular
Sleep- Adequate
Addictions - 1-2 beers/month
SURGICAL HISTORY:
No previous surgical history
FAMILY HISTORY:
NO SIGNIFICANT FAMILY HISTORY
GENERAL EXAMINATION:
Patient is C/C/C
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Vitals:
BP- 130/80mmhg
Orthostatic Hypertension:
Supine position - 130/90mmhg
Standing position - 120/100mmhg
PR- 86bpm
RR- 18cpm
SpO2 - 99% @ Room air
SYSTEMIC EXAMINATION:
CVS: S1,S2 heard ,no murmurs
RS: BAE +.
P/A: soft, non tender,
Bowel sound heard
CNS:
Right. Left
Power- UL- 5/5. 5/5
LL- 3+/5. 3+/5
Tone- UL- N. N
LL- Decreased
Reflexes- B. T. S. A. K. P
Right- - - - - - -
Left-. - - - - -. -
Blood urea- 28
RBS- 83
Serology - NR
S.Electrolytes:
Na- 142
K+- 4.3
Cl- 101
Ca+2 - 1.18
S. Creatinine - 0.9
DIAGNOSIS:
Treatment:-
1. Inj. OPTINEURON 1 AMP IN 100 ML NS IV OD
2. T. WYLOSONE 60MG PO OD
3. T. THYRONORM 25MCH PO OD
4. VITALS MONITORING
Gait on 28/2/2023
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