A 55-year-old male patient came to general medicine OPD with the cheif complaints of burning sensation in left leg and arm

Hi, I am M. Sohith Mahadeva Reddy of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.





The patient’s consent was taken verbally prior to history taking and examination of his/her condition.


A 55-year-old male laborer from Nomula village of Nakrekal came to general medicine OPD with the cheif complaints of burning sensation in left leg and arm since 3 days 


HISTORY OF PRESENT ILLNESS:

He was apparently asymptomatic 3 days ago
From 3 days, he developed episodes of burning and tingling sensation in both upper and lower limbs, which were insidious in onset and lasted for 30 minutes and subsidies on physical activity. 
The episodes were associated with tetanus in the fingers when he tried to lift his hand straight above his head .
The burning sensation starts in the proximal limbs and extends to the distal fingers.
In the lower limb, he has cramps in the calf region, pricking sensation on his plantar surface and toes.
The episodes were associated with fever, chills, and dragging type of bilateral neck pain, which were relieved on taking medication.


PAST HISTORY: 

6 years ago, he suffered from blunt force trauma to head in a quarrel, due to which he developed left sided hemiplegia for which he went to Gandhi hospital and used medication, but the symptoms were not relieved.
No H/O DM, HTN, epilepsy, asthma, TB.


FAMILY HISTORY: 

No H/O DM, HTN, TB, epilepsy, asthma


PERSONAL HISTORY: 

Inadequate sleep since 2 months due to financial stress 
Mixed diet 
Decreased appetite since 1 year
Constipated bowel since 15 days
Normal micturition 
No allergies 
Alcohol- 180 ml 6-7 times per month since 30 years 
Bidi- 45 pack years


DRUG HISTORY: 

PPIs OD since 7 years


GENERAL EXAMINATION: 

The patient was conscious, coherent, and cooperative 
No pallor 
No icterus 
No clubbing of fingers
No cyanosis
No lymphadenopathy 
No pedal edema 

VITALS:

HR- 78bpm
BP- 120/80 mmHg
RR- 16 cpm

LABORATORY INVESTIGATIONS: 


2D ECHO REPORT:

ECG:


























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