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.
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
Comments
Post a Comment