46/M with Peripheral Neuropathy

 Welcome to my blog! I am Varshitha Kalidindi, a 2nd year medical student. This is an e-log to discuss our patient's de-identified health data after taking informed consent of the patient. It also reflects patient centered online learning portfolio.

I will be looking forward to some feedback and valuable inputs through the comments box provided below.

I have been given this case 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, diagnosis and treatment plan.

CASE:-

A 46 year old male came to the OPD with complaints of burning sensation in the feet (bilaterally) since 6 months.

The pain was not associated with pedal oedema, tingling/numbness. There was no slippage of foot.

Also, it wasn't associated with tingling and numbness/ hyperpigmentation of skin

There was history of recurrent episodes of running nose, sore throat, cough (maybe due to allergic rhinitis)

There was also history of trauma to the left leg, erythematous patch was seen on the left leg which subsided by itself. History of oozing is present.

HISTORY OF PRESENT ILLNESS:-

The erythematous patch on the left leg was followed by itchy lesions of dorsum of feet bilaterally. Hyperpigmented lesion on both feet with lichenification of right foot.

HISTORY OF PAST ILLNESS:-

Not a known case of hypertension, diabetes mellitus, tuberculosis, epilepsy, CVA

TREATMENT HISTORY:-

No significant treatment history.

PERSONAL HISTORY:-

Appetite: normal

Diet: mixed

Bowels: regular

Micturition: normal

The patient has history of atopy. No habits or addictions

FAMILY HISTORY:-

No family history of diabetes, hypertension, heart disease, stroke, cancers, tuberculosis, asthma

PHYSICAL EXAMINATION:-

No pallor, icterus, cyanosis, clubbing of fingers/toes, lymphadenopathy, oedema of feet, malnutrition, dehydration

VITALS:-

Temperature: afebrile

Pulse Rate: 70bpm

Respiratory rate: 12 breaths per minute

BP: 140/100 mm of Hg

SPO2: 99%

GRBS: 109mg%

SYSTEMIC EXAMINATION:-

CVS: S1, S2 sounds heard

Respiratory system: No dyspnoea, position of trachea is central, breath sounds are vesicular.

Abdomen: shape of abdomen is obese, bowel sounds heard, genitals are normal.

CNS: The patient was conscious and alert.

DIAGNOSIS:- Peripheral neuropathy, Lichen Simplex Chronicus

INVESTIGATIONS:-

ECG:-

Blood Sugar Fasting:-

Serum Creatinine:-

Post Lunch Blood Sugar:-

Serum Electrolytes (Na, K, Cl):-

Blood Urea:-

Complete Urine Examination (CUE):-

Glycated Haemoglobin:-

Cross Consultation Notes and Treatment:-

Psychiatry:-

ENT:-

                                

DVL:-

CLINICAL FINDINGS:-

46/M was brought to casualty with complaints of burning sensations in the feet (bilateral). It was not associated with pedal oedema, tingling/numbness, hyperpigmentation of the skin. There was no slippage of the foot. There was history of recurrent episodes of running nose, sore throat, cough, possibly due to allergic rhinitis. There was also history of trauma to the left leg, erythematous patch was seen on the left leg which subsided by itself. History of oozing is present. This was followed by itchy lesions of dorsum of feet (bilateral). Hyperpigmented lesion on both feet with lichenification of right foot were seen.

Personal History: Diet is mixed. Appetite is normal. Sleep is adequate. Micturition is normal. Bowel movements are regular. No habits/addictions.

Examination: Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, cyanosis, lymphadenopathy, clubbing, oedema.

Vitals: Temperature: afebrile

Pulse Rate: 70bpm

Respiratory rate: 12 breaths per minute

BP: 140/100 mm of Hg

SPO2: 99%

GRBS: 109mg%

CVS: S1, S2 heard, no murmurs

Respiratory system: No dyspnoea, position of trachea is central, breath sounds are vesicular.

Abdomen: shape of abdomen is obese, bowel sounds heard, genitals are normal.

CNS: The patient was conscious and alert.

Investigations:-

   Fasting blood sugar-92mg/dl (70-110)

   Serum creatinine-1.1mg/dl (0.9-1.3)

   PLBS-117mg/dl (0-140)

   Serum electrolytes- Na: 132mEq/L (136-145), K: 4.3mEq/L (3.5-5.1), Cl: 106mEq/L (98-107)

   Blood Urea- 16mg/dl (12-42)

   CUE- normal

Diagnosis:- Peripheral neuropathy, Lichen Simplex Chronicus