A 60year old male with pain in bilateral lower limbs.

May 16, 2022

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 60year old farmer ( 2acres of cotton and 1acre of wheat crop ) by occupation (stopped working).came with chief complaints of both lower limb and pain since 10days.

PATIENT DAILY ROUTINE

Patient wakesup at 5:00am and leaves for work like grazing cattle,keeping water for field,or else he wakes up at 7:00am.

Patient brushes,drinks,tea,goes out talks with friends and returns back at 9:00am to eat rice with either dal, chicken,mutton,fish.

He goes to field when he is having work like drying of wheat grains,removing weeds in his fields,if there is no work,then he chats with his friends or else sleeps at home.From 2months he's supervising his workers in cotton field and completes it by 9:00pm ,eats food (rice+curry),sleeps at 10:00pm.

Patient is a chronic smoker since 40years and alcoholic occasionally(90ml once in 10days).

Patient drank alcohol 10days back and the next day patient experienced pain in right calf region , right thigh region. He was taken to local hospital , routine investigations and symptomatic treatment was given.He used those medications for 5days and no relief of any symptoms seen. Because of this pain patient could not be able to do his activities like going to field and supervising the work and now presented with these complaints to our hospital for further management.

HOPI

Patient was apparently asymptomatic 10days back and later developed both lower limb weakness and pain in lower limbs which is gradual on onset and aggravated while walking for some distance.

PAST HISTORY

Patient is a known case of diabetic 4years back and patient used medication for 1month and then discontinued medication.

No history of HTN,CAD,ASTHMA,PTB,HYPOTHYROID, EPILEPSY.

PERSONAL HISTORY:

Appetite -normal

Bowel and bladder-Regular

Micturition-normal

Addictions-smoker since 40years.

On EXAMINATION.

Temp-Afebrile

Pr-90

Cvs-s1s2 heard