A 75 YEAR OLD MALE

January 25, 2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

Chief complaints:

A 75 yr old male came to the opd with

C/O Needle prick sensation of both hands and legs since 1month

C/O Stomach since 1month

C/O Headache since 10 days

Hopi:

Patient was apparently asymptomatic 1 month back then he had needle prick sensation in both hands and legs only at night no decreased sensations

C/O stomach pain in epigastric region only after eating food and complaints of regurgitation of food ,no tenderness,no nausea,no vomiting.

C/o headache and giddiness since 10 days,headache is diffuse type ,no photophobia,no phonophobia c/o neck pain since 10 days no restriction of movements associated with giddiness,no loss of consciousness,burning micturition+,hematuria+,increased frequency of urine,no hesitancy ,no urgency,no loose stools,blood in stool+

B/L knee pain since 6 months,pain increases while walking,swelling is present in left popliteal fossa

Past illness:

H/O trauma to head 10 days back

H/O hemorroidectomy 4 yrs back

H/O hydrocoele 10 yrs back

N/K/C/O DM,HTN,TB,EPILEPSY,CVA

Personal history:

Diet:Mixed

Appetite:Normal

Sleep:Normal

Bladder movts: hematuria +,intermittent

Bowel movts:bleeding per rectum