GM - 02

February 25 2023
Case 2
February 25 2023

Hi , I am V.Shivani 3rd Sen dental student. This is online elog book to discuss our patient health data after taking her consent. This also reflects my patient centered online learning portfolio .
CASE SHEET : A 27 year old male came with complaint of weakness of both upper and lower limbs .
CHIEF COMPLAINTS :
Weakness of limbs from 1 week
Severe squeezing type of pain in lower limbs from 1 week
Shivers and numbness in lower limbs from 5 days

HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 1 week back ,then he developed pain in both upper and lower limbs and had shivers. The pain first developed in feet and progressed gradually .

PAST ILLNESS :
No Hypertension 
No Diabetes mellitus
No past history 

PERSONAL HISTORY :
Diet - Mixed diet 
Appetite - loss of appetite
Sleep- normal
Bowel and bladder - Normal bladder movement 
No bowel since 2 days 
Addictions - Alcohol occasionally 

FAMILY HISTORY : 
Diabetes - no
Hypertension - no

GENERAL EXAMINATION :
Built - well built
Nourishment - well nourished
Consciousness - in conscious 
Pallor - pale pink
Cyanosis - no
Clubbing - no
Edema - no
Lymphadenopathy - no
https://drive.google.com/uc?export=view&id=11ahOdncyr44iNKJQgCg0sZNImV_9NZBfhttps://drive.google.com/uc?export=view&id=1ileWrhPPc1Hmq8TOOGpnWjccZIgRRGsQhttps://drive.google.com/uc?export=view&id=1PzZujv2TULMjsDw5hSHLRre8MQ7XPQpR
VITALS:
Temperature - 98.6 C
Blood pressure - 130/80 mm of Hg
SpO2 - 99%

PROVISIONAL DIAGNOSIS :
NEUROPATHY

Q/A
1. Are there any other possible causes ? 
2. Does alcoholism has anything to do with patient’s condition ?

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