30year old male came with complaints of lower backache since 2days.

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' problems through series of inputs from available global online community of experts with an aim to solve those patient's 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 the 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. 

  

Case:A 30year old male was brought to OPD by his mother with chief complaints of lower backache since 2days and bilateral pedal edema since 2days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2days back and later developed lower backache which gradually increased while walking.Patient is unable to talk since childhood.

No h/o fever,nausea, vomiting.

No h/o fall,trauma,nvd-delivery at home.

H/0 PICA  at the age of 5YEARS .

HISTORY OF PAST ILLNESS:

                       Patient had delayed developmental milestones and  achieved by the age of 10years.

History of siezure 12years ago subsided with medication.No similar episodes are seen afterwards.

PATIENT DAILY ROUTINE

Patient wakesup at 6am and does his personal activities with help of his mother and will have breakfast by 9am and goes to the field and does some work and take rest for sometime. He will have lunch by 1pm and sleeps for 2hours and goes to home by 5pm and does bath with help of his mother and has dinner at 8pm and sleeps by 10pm.

Treatment history:

NO History of DM ,HTN,ASTHMA,CAD,CVA.

 ON EXAMINATION

VITALS on admission

TEMPERATURE - Afebrile

PULSE RATE - 84 bpm

BLOOD PRESSURE - 

90/60 mmHg

RESPIRATORY RATE - 18cpm

SPO2 - 98% @ RA

GRBS 108MG/DL

Minimental state examination score

1/30

PROVISIONAL DIAGNOSIS

Intellectual disability under evaluation. ?proximal myopathy