Final year General Medicine Short case presentation

M.ANURAG

ADMISSION NO : 1701006098

This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

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 diagnosis and treatment plan.

A 50 YEAR OLD MALE PATIENT BROUGHT TO THE HOSPITAL WITH WEAKNESS IN BOTH THE LOWER LIMBS

CHIEF COMPLAINTS:

A 50 year old male patient presented with weakness in both the lower limbs bilaterally since 2 days.

The patient is a resident of Nalgonda, and a daily wage worker by occupation untill one year ago. He had a fainting episode following which he stopped going to work.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 4 months back then he developed pain in the right hip region, which was insidious in onset and intermittent at the beginning. Aggrevated on movement and relieved on rest and medication.

He went to the hospital 2 months ago when the pain progressed and became continuous, and was diagnosed with avascular necrosis of the femur due to a trauma to the hip one year ago.

2 days ago, patient developed weakness in the lower limb which progressed upto the hip.

He was taken to the hospital and was prescribed medications. On starting the medication, the weakness worsened.

The next morning, patient required assistance to walk and sit up but was able to feed himself. The weakness progressed so that by the evening he was unable to feed himself. He only responded if called to repeatedly.

Patient also had blood in urine, one month back for 5 days continuously, but did not go to the hospital.

The weakness was not associated with loss of consciousness, slurring of speech, drooping of mouth, seizures, tongue bite or frothing of mouth, difficulty in swallowing.

No complaints of any headache, vomitings, chest pain, palpitations and syncopal attacks.

No shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain or burning micturition.

PAST HISTORY-

No similar episodes in the past.

Patient is a known case of diabetes since 12 years. He is on regular medication, with 15 U in the morning before breakfast and 10 U in the evening (7-7:30pm).

He was hospitalized, 4 years ago with low blood sugar, and was admitted for 10 days. He presented with altered mental status.

No history of hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD.

No surgical history.

PERSONAL HISTORY-

Diet: Mixed

Appetite: Normal

Sleep: Adequate

Bowel and Bladder: Regular

No allergies

Started alcohol intake 25 years back, and stopped 12 years when diagnosed with diabetes. He used to binge drink alcohol for 10 days continuously every month and then used to stop for 20 days. Cycle repeats every month. Now, consumed alcohol only on special occasions, doesn't exceed 90ml.

Started smoking beedis, one a day, 10 years ago.

Stopped 4 years ago when he went into a hypoglycemic episode, but has resumed one year ago.

FAMILY HISTORY-

No similar history in family.

GENERAL EXAMINATION-

Patient is examined in a well lit room after taking informed consent.

Patient is conscious, coherent and cooperative.

He is moderately built and moderately nourished.

Pallor: Present

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Generalized Lymphadenopathy: Absent

Edema: Absent

VITALS

Blood Pressure: 124/72 mmHg

Respiratory Rate: 17 cycles per minute

Pulse: 70 bpm

Temperature: Afebrile

SYSTEMIC EXAMINATION:

CENTRAL NERVOUS SYSTEM EXAMINATION-

Higher mental functions

- Conscious
- Oriented to person and place
- Memory - Able to recognise their family members and recall recent events
- Speech - no deficit

Cranial nerve examination

• 1 - couldn't be elicited

• 2- Direct and indirect light reflex present

• 3,4,6 - no ptosis Or nystagmus

• 5- corneal reflex present

   • 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present

  • 8- able to hear

• 9,10- position of uvula is central

• 11- sternocleidomastoid contraction present

• 12- no tongue deviation

Motor system

Attitude - right lower limb flexed at knee joint

Reflexes
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee 2+ 2+
Ankle 2+ 2+

Superficial reflexes and deep reflexes are present , normal

Muscles power:

Right            Left
Upper limb
Elbow - Flexor 5/5             5/5
- extensor 5/5             5/5
Wrist - Flexor 5/5              5/5
- extensor 5/5              5/5
Hand grip 5/5 5/5

Lower limb
Hip - Flexors 5/5              5/5
- extensors 5/5              5/5
Knee - Flexors                5/5              5/5
- Extensors           5/5              5/5
Ankle - DF 5/5 5/5
- PF 5/5               5/5
EHL 5/5 5/5
FHL 5/5 5/5

    Right Left

BULK
Arm
Forearm    19cm 19cm
Thigh 42cm. 42cm
Leg 28cm. 28cm

TONE
Upper limbs N N
Lower limbs N N

Gait is normal
No involuntary movements

Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are normal

CARDIOVASCULAR SYSTEM

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

PALPATION:

Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

RESPIRATORY SYSTEM

INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Apical Impulse is not appreciated

Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

PALPATION:

Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated

PERCUSSION:

The following areas were percussed on either sides-

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower interscapular were all RESONANT.

AUSCULTATION:

Normal vesicular breath sounds heard

No adventitious sounds heard.

ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion over abdomen- tympanic note heard.

AUSCULTATION:

Bowel sounds are heard.

INVESTIGATIONS :

HEMOGRAM
Hemoglobin: 8.6
TLC: 18380
N/L/E/M: 86/06/1/5
Platelet: 2.02
MCV: 71.6
MCH: 24.2
RDW: 15
PCV: 26.4
RBC COUNT: 3.63

ELECTROLYTES
Na: 145
Cl: 110
K: 2.5

RENAL FUNCTION TESTS
Urea: 74
Creatinine: 3.7
Urine protein / creatinine: 0.27
Spot urine protein: 14.2 mg/ dl
Spot urine creatinine: 51.1mg/dl