tingling

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 reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”


A 50 year old tailor from nalgonda came to opd 

PRESENTING COMPLAINTS:
Tingling and numbness in right side lower limb upper limb and face since 1 year

HISTORY OF PRESENTING ILLNESS:
Apparently asymptomatic 4 years back when she developed severe back pain insidious in onset and gradually progressive,which radiated to buttock for which she visited a hospital and was told there was lumbar gap for which she underwent physiotherapy
The pain reduced from unable to walk ten step 4 years back to occasional pain relieve on rest
1year back when she noticed tingling and numbness suddenly started when she was eating from sole of foot and ascended to upper limb and face
They last 5-10 minutes and resolve
They are irregular sometimes occur 2-3 times a week always in the morning




 SPINOMOTOR SYSTEM
No. Wasting/Thinning of muscles

 SENSORY SYSTEM
a.No sensory deficit 
b. numbness and tingling sensation present in upper and lower limbs right
In right side of face
c. back pain previously
3-4 years back 
Presence of lumbar gap? 
Physiotherapy done

There is unsteadiness on closing the eyes
Sensation of someone dragging her back since 2 weeks

 HIGHER MENTAL FUNCTIONS
Present

CRANIAL NERVES
I – alteration in smell no 
II – blurring of vision/diminished vision, differentiate colours, night blindness glass
III, IV, VI – drooping of eyelids/ double vision/ able to move eyes in all directions 
V – having sensation over the face, able to chew food
VII – able to close the eyes and lips, deviation of angle of mouth, drooling of saliva, able to 
feel taste of objects
VIII – hard of hearing, tinnitus, vertigo
IX, X – difficulty in speech, nasal twang to speech, regurgitation of feeds, difficulty in 
swallowing
XI – move the neck in all directions, lift the shoulder
XII – able to roll the tongue and push the food backwards
 CEREBELLUM
unsteadiness while walking is present occasionally
 AUTONOMIC NERVOUS SYSTEM
Normal
 MENINGES 
No signs of Memingeal irritation
RELEVANT NEGATIVE HISTORY:
No history of muscle weakness
No history of loss of sensation
No history of loss of speech
No history of difficulty in movement
No history of involuntary movement

a.No trauma, , headache
No medication 
PAST HISTORY:

Known case of Diabetes, 1 year 
Known case of Hypertension 3 years
,not a known case of coronary artery disease, thyroidal 
illness, Tuberculosis, HIV, malignancy

Operation for piles done 1 year 
Hysterectomy done 2 years
PERSONAL HISTORY:
a. Married
b. non-veg
c. Sleep pattern is normal
d. Smoking no 
e. Alcohol no 
f. Drug abuse no 

FAMILY HISTORY:
Not significant
MENSTRUAL HISTORY AND OBSTETRIC HISTORY – FEMALES:
a. Menarche 
b. Regular
c. No. of children 2
d. Full term LSCS
e. Obstetric complications none
f. Menopause
TREATMENT HISTORY:
a. Previous Treatment

b. Present Treatment

SUMMARY:
1. Onset – acute
2. Progression – static, 
3. Disease – ? 
4. Structures involved – cortex/brain stem/ long tracts/ anterior horn cells/ anterior or 
posterior nerve roots/ peripheral nerves/ myoneural junction/ muscles/ 
cerebellum/extrapyramidal/autonomic
5. Levels – Single/Multiple
6. Etiology – Trauma/vascular/infective/inflammatory/degenerative/demyelinating 
/malignancy
PHYSICAL EXAMINATION

GENERAL EXAMINATION:
Patient is conscious
Oriented
Comfortable
Co-operative
Moderately Built
Moderately Nourishment
afebrile
Palor no
Icterus no
Cyanosis – no
Clubbing – no
Pedal edema – no
No lymphadenopathy

VITAL SIGNS
PULSE: 82 beats
BLOOD PRESSURE: __120/80___mm of Hg measured in the _____ Upper limb with the patient 

RESPIRATORY RATE: ___17_/min
TEMPERATURE: afebrile

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