Gm case 3

A 37 year old male with numbness in the right hand and fingers.
September 25,2023

 Hi, I am s.Alekhya, 5th semester medical student. 

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 a diagnosis and treatment plan.

CONSENT AND DE-IDENTIFICATION : 
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.


Case scenario:


A 37 year old male driver by occupation came to the opd with cheif complaints of numbness in the right hand and fingers along with neck pain.

History of present illness:

The patient was apparently assymptamatic 20days ago ,then developed nunbness in the right hand and fingers and he also have swelling of the fingers.

10 days ago he visited the local doctor and used some medications, but there is no change in the symptoms .

-> No history of diarrhoe, constipation,cough,burning micturition,fever.

->symptoms are aggrevated by exertion but no relieving factors.


History of past history:

-  No History of similar complaints present in the past.
- N/K/C/O HTN, DM, TB, CVD, Asthma, Epilepsy, Thyroid disorders, blood transfusions. 

Surgical history:

- no pervious surgical history.

Family history: 

No significant family history.

Personal history:

-married
-mixed diet
-normal appetite
-adequate sleep
-normal micturition
-regular bowel movements
-addictions:occasional consumption of alcohol which is steopped 1month ago.

GENERAL EXAMINATION:

I have examined the patient after taking prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and well nourished
- no pallor
- no icterus
- no cyanosis 
- no clubbing of fingers
- no lymphadenopathy 
-no pedal edema
-no malnutrition






VITALS:

- Temperature: afebrile 
- Pulse rate: 78 bpm, regular rhythm, normal volume
- Respiratory rate: 24 cpm
- BP: 130/80mm Hg
- SPO2: 98% at RA.







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