46year old male patient with lowe limb bilateral numbess tingling sensation,back pain, giddiness and hypo pigmentation in hand
NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.
Case:
A 46YEARS OLD MALE CAME WITH THE CHIEF COMPLAINTS OF Bilateral numbness and tingling sensation on lower limb, giddiness ,back pain and hypo pigment patches over hands
CHIEF COMPLAINTS:
A 46year old male patient came with the chief complaints of:Bilateral numbness and tingling sensation on lower limb, giddiness ,back pain and hypo pigment patches over hands
HOPI:-
The patient was apparently asymptomatic 1month back then complained of of:Bilateral numbness and tingling sensation on lower limb after a trauma in onset, insidious in onset
he had lower Bach pain since 1year and hypo pigment patches over hands
No aggrevating and relieving factors.
No c/o deviation of mouth , loss of consciousness, headache, giddiness, vomitings, Pain
No H/o involuntary passage of urine or stools
No H/o fever , loose stools , sob , pain abdomen.
No h/o visual disturbances, headache, diplopia, ptosis, he is able to appreciate smell, he is able to look towards all sides no h/o sensory loss over the face, no facial deviation.
No noted sensory deficit as the patient was able to feel clothes, feeling hot and cold water while bathing.
No h/o auditory disturbances
No h/o restricted tongue movements
No difficulty in swallowing
No difficulty in speaking
No h/o abnormal sweating
No h/o shooting pain
No h/o headache or vomiting.
No h/o seizures
No h/o Fasciculations/muscle twitchings.
No h/o Involuntary movements like chorea, athetosis, hemiballismus
PAST HISTORY:
Not a known case of diabetic mellitus,asthma, hypertension, tuberculosis, epilepsy, coronary artery disease, cerebrovascular accidents.
No similar complaints in the past
No previous surgical history
PERSONAL HISTORY:
Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: nirmal
Habits: occasional alcoholic
No history of allergy
Family history:
Insignificant
GENERAL EXAMINATION:
The patient is examined in a week lit and well ventilated room
Moderately built and moderately nourished
pallor present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
VITALS:
Temperature: febrile
Pulse: 32beats per minute, regular
Respiratory rate: 16 cycles per minute
Blood pressure: 130/90 mm of Hg
CNS EXAMINATION:-
Sensory
Rt. Lf
Fine touch. Felt. Felt
Crude touch Felt. Felt
Vibration. Felt. Felt
Sterognosis Felt. Felt
Pain Felt. Felt
Bulk
rt lf
Arm 30cm 30cm
Forearm 26cm 26cm
Leg 31cm 31cm
Tone
rt lf
Arm normal normal
Leg normal normal
Power
rt lf
Upper limb 5/5 5/5
Lower limb 5/5 5/5
-normal gait
Cerebellar signs
No coordination seen in finger nose test.
No coordination seen in knee heel test.
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