27 YEAR OLD MALE

Name: KP PRANAY 

Roll no. 81

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-.        -         -        -       -       -.      -

Gait-

INVESTIGATIONS:

On 22/02/23

Hemogram -

CUE-

Blood urea- 28

RBS- 83

Serology - NR

S.Electrolytes:

Na- 142

K+- 4.3

Cl- 101

Ca+2 - 1.18

S. Creatinine - 0.9

LFT-

X-Ray-

ECG-

DIAGNOSIS:

?AIDP

?ACUTE SENSORY MOTOR AXONAL NEUROPATHY

TREATMENT:

On 22/02/23-

Inj OPTINEURON 1AMP IN 100ML NS IV/OD

PHYSIOTHERAPY OF BOTH LOWER LIMBS