Harshith’s ELOG

December 19, 2020

19 december 2020

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's 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.

Here is a case i have seen:

45/M patient who worked as daily wage labourer and stopped working since 3 years.

Patient was a chronic alcoholic 6 yrs back ,with history of multiple episodes of binge alcohol intake and falls .

Patient was often found unconscious on the roads or near the wine shop ,and was brought to home by the local people .After fall and knee injury pt 7yrs back he was convinced to stop alcoholic,which he stopped for 1month,went for work and again started drinking for 3yrs and he continued to fall on roads.After which they took him to many hospitals for his alcohol dependence and was warned about all the side effects then he stopped alcoholic (that is 4yrs back)

Diagnosed with hypertension 4yrs back

6 years back patient had history of alcohol intake and fall - following which he sustained injury to both knees and was brought to our hospital.

He was said to have no fractures and was prescribed analgesics and sent home .

Since then patient stopped taking alcohol .

Patient wife says he developed-- gradual onset of slurring of speech since 6 years - non progressive

With no deviation of mouth ,drooling of saliva ,heaviness or weakness of limbs ,or seizure like activity .

He complained of pain in both lower limbs 3 years back ,for which he stopped working.

Since one month patient is complaining of difficulty in walking ,that aggravted since 10 days ,when patient attenders noticed that he is walking only with support .He is father of 2sons and one daughter,all of them go to work leaving him and his daughter at home

Even after he stopped going to work he used to do his daily activities like brushing bathing and takes care of his 7yr old daughter,he used to go so far and get vegetables,but since 10days he is not able to go to bath by himself,swaying while walking+,taking support of walls and stick while walking

He also gives history of washbasin attacks +

There is history of giddiness or instability while walking without support or when he stands with legs together .

There is also little difficulty in getting up from squatting position

On asking patient's wife -

She says patient has tremors while he approaches to take a cup a tea ,no spillage of tea or water on clothes .

No slippage of footwear ,no difficulty in dressing and undressing,no difficulty in combing ,no difficulty in mix food ,no difficulty in chewing , swallowing ,

No tingling or numbness

Personal history-

patient has a mixed diet with normal appetite with regular bowel and bladder movements, with adequate sleep

Chronic alcoholic since 25 years,consumes beedi since 25 years

On examination :

Patient is conscious ,oriented to time ,place ,person

Thinbuilt and ill nourished

Vitals- Temp- afebrile Bp- 130/100 mmhg Pr- 86 bpm Rr- 16 cpm