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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