Medicine case

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Case presentation:

HOPI

   Pt. Was apparently normal 10days ago , then developed gradual onset weakness , progressive in nature in B/L UPPER LIMB AND LOWER LIMB. 

  He also reported one episode of fever spike (low grade) subsided on medication 2days ago. Next day morning , pt. was going back to home on bike during which he had giddiness and unable to move his limbs and ride furthur. So he stopped and took rest on road during which he collapsed . Then he was seen by a bypasser who then informed his family members after which they took him to home and called an RMP to his home.  

   No h/o trauma , external injuries. RMP gave him few injections and tablets. Next day he came to Kamineni OPD. 

   Pt. Even complaints of dragging type of pains in B/L UL AND LL., since 10days. Tingling present. No ,c/o numbness and paresthesias

  Pt. Initially had weakness in pressing accelerator while driving car since 10days then after 5days notices decrease in hand grip and unabke to  lift weights( which he had carried before eg. Bag of vegetables, rice bag). But no history of difficulty in climbing stairs., mixing food., no h/o difficulty in getting up from squatting posture. No difficulty in combing hair. No bowel and bladder incontinence. No difficulty in buttoning and unbuttoning.

   No h/o diplopia , blurred vision ., anosmia., no facial deviation, drooling of saliva. No difficulty in swallowing., speech and breathing. No h/o ataxia and difficulty in walking. No gait abnormalities.

H/o low back ache

h/o difficulty in getting up from lying in bed,in mornings after getting up from sleep. Has stiffness in body for atleast 30min.  Which resolves on itself.

no h/o difficulty in holding pen/buttoning/unbuttoning

no h/o difficulty in breathing 

no h/o difficulty in lifting the head off the pillow

no h/o difficulty to roll over the bed

no h/o involuntary muscles

no h/o fasciculations/muscle twitchings

h/o slippage of chappal while walking without knowledge

no h/o sensory deficit in feeling clothes

no h/o sensory deficit for hot/cold

no h/o tingling and numbness in UL & LL

no h/o band like sensation

no h/o trauma 

no h/o giddiness while washing face

no h/o cotton wool sensation

no h/o urgency/hesitancy/increased frequency of urine

no h/o urinary incontinence

h/o fever/

No h/o nausea/ vomiting/diarrhea

no h/o seizures

no h/o spine disturbances

no h/o head trauma

no h/o loss of memory

no h/o abnormality in perception of smell

no h/o blurring of vision

no h/o double vision/difficulty in eye movements

no h/o abnormal sensation of face

no h/o difficulty in chewing food

no h/o difficulty in closing eyes

no h/o drooling of saliva

no h/o giddiness/swaying

no h/o difficulty in swallowing

no h/o dysphagia/dysphasia

no h/o tongue deviation

no h/o difficulty in reaching objects

no h/o tremors/tongue fasciculations

no h/o incoordination during drinking water

no h/o fever/neck stiffness

Past history:

no h/o similar complaints in past

not a known case of DM/HTN/EPILEPSY/CVA/CAD

Past Surgical:- pt.has undergone a surgery of ORIF WITH PLATING of right radius as a treatment for right radius fracture

personal history:

mixed diet with normal appetite and normal bowel/bladder movements

 H/o smoking since 10yrs., 10 to 15 cigarretes/day

Not an alcoholic

no significant family history.

Pt. Is not allergic to any foods and any drugs he has consumed till now

General examination:

Moderately built ; moderately nourished

afebrile

Pallor absent

Icterus negative

No cyanosis,clubbing,lymphademopathy,Edema.

no short neck

no scars;no h/o tropic ulcers

no neurocutaneous markers

Bp 120/80 mmhg.rt. hand sitting position

Pr 80 bpm, regular, normal volume

CNS :--s1 s2 hears no murmurs

RS  :-- bae + nvbs heard., no added sounds

P/a soft ,nontender

CNS:-

{DAY 1}

 HMF

        oriented to place/time/person

no h/o aphsia/dysarthria

no h/o dysphonia

no h/o memory loss

no h/o emotional lability

MMSE- 30

cranial nerves- intact

MOTOR SYSTEM

                                              Right.         Left

Bulk:    inspection      NORMAL      NORMAL

             palpation.       NORMAL      NORMAL

Measurements  U/l   28.5cm.         28.5cm

                             L/L   37 cm             37 cm

Tone:               ul.         NORMAL   NORMAL

                         LL.        NORMAL    NORMAL

Power              UL.                

                 Biceps                 5/5.          5/5

                 Triceps                5/5           5/5

              Supinator              5/5         5/5

               iliopsoas                4+/5.              4+/5

   adductor femoris            4+/5.              4+/5

       gluteus medius            4+/5.             4-/5

   gluteus maximus            4-/5.             4+/5

              hamstrings            4+/5.             4+/5

quadriceps femoris          4+/5.              4+/5

tibialis anterior.                 4+/5.             4+/5

tibialis posterior.               4-/5.              4-/5

peroneii.                              4-/5.             4-/5

gastronemius.                   4+/5.           4+/5

extensor -

         digitorum longus.      4+/5.               4+/5

flexor digitorum longus      4+/5.               4+/5

   Superficial reflexes

                       Right.           Left

Corneal.            P                  P

Conjunctival    P.                  P

Abdominal.      +                  +

Plantar          mute         extensor

cremasteric.    +                +

    Deep tendon reflexes 

                     Right.             Left

Biceps.          ++ +                   ++

Triceps.         ++.                   ++

Supinator.     +++                 ++

Knee              +++                 +++

Ankle.            ++                ++

 

SENSORY SYSTEM 

                           

SPINOTHALAMIC 

             crude touch   .   N.                   N

                 pain.               N.                   N

            temperature .     N.                   N

post:

             fine touch.         N.                   N

             vibration.           N.                   N

     position sensor.        N.                   N

 cortical  

 2 point discrimination  N.                   N

tactile localisation.        N.                   N

CEREBELLUM

titubation - absent

ataxia - absent

hypotonia.                Normal             Normal

Based on above findings the following investigations were done::-

INVESTIGATIONS

ECG:__

CHEST X-RAY PA VIEW::--

SEROLOGY::--

HIV -- NEGATIVE

HCB antibodies  -- NEGATIVE

HbsAg antibodies -- NEGATIVE

CUE:--

  Urine- pale yellow colour., Appearence is clear., specific gravity :- 1.010., albumins and sugars are nil. Bile salts and Bile pigments - Nil.,, Pus cells:- 3-4., RBC , CRYSTALS, CASTS-- NIL

RBS::--

CBP : 

HB            13.9gm/dl

Platelets  1.5lakhs/cumm

TLC            7,500 cells/cumm

Neutrophils  70%

lymphocytes 25%

smear -normocytic normochromic anemia

RFT::--

Sr. Urea 39

Sr. Creatinine 3.5

Uric acid  3.0

Na+ 137 meq/l

k+.    3.7meq/l

cl-.       101meq/l

Calcium  9.2

TREATMENT GIVEN :-

1.INJ.OPTINUERON 1ampoule in 100ml NS IV

2. Tab. Pan 40mg OD

DAY.-2 :-

The patient felt subjectively better compared ot yesterday .

-- when asked to remove his shirt ., he felt a little difficulty in his grip.

Treatment given on day 2:-

1.Inj . Optinueron 1amp in 100ml NS iV

2. Tab. Ultracet BD 

        

    

  

Advices at Discharge

Follow Up

When to Obtain Urgent Care 

Preventive