A 48 yr old man presented with weakness in lower limbs and burning sensation of feet

Hi, I am princy rose , 5 th sem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.




June 7,2023

Case scenario......





CASE SHEET:




A 48 year old male farmer by occupation,resident of chintapalli came to the opd with chief complaints of 

WEAKNESS OF BOTH LOWER LIMBS SINCE 6MONTHS

BURNING SENSATION OF FEET SINCE 1 MONTH

HOPI::

Pateint was asymptomatic 6 months back then he developed weakness of both lower limbs which is insidious in onset and gradually progressive.

Associated with burning sensation of feet and pain in the calf muscle

Patient also complaint of losing footwear while walking

Patient also complaints of tingling sensation in both feet but can't appreciate it became burning sensation is more

Patient was able to walk on his own till I month back but since 1 month patient needs supply to walk

Visited local hospital 6 months back and using treatment since then


PAST HISTORY


No history of hypertension, diabetes, thyroid,epilepsy,asthma,CAD CVA

No surgical history

No blood transfusions



PERSONAL HISTORY: 


Diet:mixed


Sleep:regular 


Appetite: Normal appetite since 3 days back .but has decreased appetite since 1 month 


Bowel and Bladder Movements : Regular 


Addictions::He had a history of taking alcohol since 25 years and stopped one year back


Family history: Not significant




General examination::


Patient is conscious,cohorent , cooperative well known with time, place, person 


He is thin built and moderately nourish


Pallor present 


Icterus: Absent 


Cyanosis: Absent 











Clubbing: Absent 


Lymphadenopathy: absent 


Edema : not seen



Vitals::


Afebrile 


PR- 94bpm


BP- 100/90mmHg 


 RR- 14cpm 


SYSTEMIC EXAMINATION


CARDIOVASCULAR SYSTEM EXAMINATION


➤s1 and s2 heard


➤Thrills absent.,


➤No cardiac murmurs



 RESPIRATORY SYSTEM



➤Normal vesicular breath sounds heard.


➤Bilateral air entry present


➤Trachea is in midline.



ABDOMINAL EXAMINATION




INSPECTION


➤Shape - Scaphoid


➤Equal movements in all the quadrants.


➤No visible pulsation, dilated veins and localized swellings.


PALPATION


➤Liver , spleen not palpable.


➤No tenderness 




CNS:  




Tone. UL. LL


Rt. Normal normal


Lf. Normal. Normal


Power of right and left UL and LL is 

5/5 and 4/5


Reflexes. B T. S. K. A. plantar


          Lt: 2+. 2+. +. 3+. -.M


          Rt: 2+. 2+. +. 3+. -. M






Provisional Diagnosis: ? Chronic inflammatory Demyelinating polyneuropathy 


 


Investigations::

Hemogram


Complete urine examination



USG



ECG


Treatment:

1. Inj OPTINEURON 1 amp 100ml NS/IV/BD

2. Tab pregabalin 75mg po/hs

3. Tab ecosprin AV 75/10 po/Hs

4. Tab Pan 40mg PO/OD








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