55 year old man with Bilateral weakness of lower limbs
FINAL PRACTICAL SHORT CASE
HALL TICKET NO 1701006067
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MEDICINE CASE DISCUSSION:
I've been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
55 YEAR OLD MALE, WHO IS FARMER BY OCCUPATION RESIDENT OF NALGONDA
Came to the opd with the CHIEF COMPLAINTS of
weakness of lower limbs since 4days
VIEW OF THE CASE :
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 4 months back when he developed pain in the right hip region, which was insidious in onset and intermittent at the beginning. Aggrevated on movement and relieved on rest and medication.
He went to the hospital 2 months ago when the pain progressed and became continuous, and was diagnosed with avascular necrosis of the femur due to a trauma to the hip one year ago.
medications:
Tab.Gabapentin&Nortryptyline
Tab.pantoprazole&Domeperidone
Tab.ETORICOXIN
THIOCOLCHICOSIDE (4mg)
Tab.METHYL COBALAMIN,Biotin
TAB.FERROUS ASCORBATE,
FOLIC ACID And ZINC TABLETS.
4 days ago, patient developed weakness in the lower limb which progressed upto the hip.
He was taken to the hospital and was prescribed medications. On starting the medication, the weakness worsened.
The next morning, patient required ASSISTANCE to WALK and SIT up, BUT FEED HIMSELF. The weakness progressed so that by the evening he was UNABLE to FEED HIMSELF. He only RESPONDED if CALLED to REPEATEDLY
NOT ASSOCIATED WITH SLURRING OF SPEECH
The weakness was not associated with loss of consciousness, drooping of mouth, seizures, tongue bite or frothing of mouth, difficulty in swallowing.
No complaints of any headache, vomitings, chest pain, palpitations and syncopal attacks.
No shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain or burning micturition.
PAST HISTORY:
No similar episodes in the past.
Patient is a known case of diabetes since 12 years. He is on insulin therapy
He was hospitalized, 4 years ago with low blood sugar, and was admitted for 10 days. He presented with altered mental status.
No history of hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD.
No surgical history.
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bowel and Bladder: Regular
No allergies
Addictions;
ALCOHOL
Started alcohol intake 25 years back, and stopped 12 years when diagnosed with diabetes. He used to binge drink alcohol for 10 days continuously every month and then used to stop for 20 days. Cycle repeats every month. Now, consumed alcohol only on special occasions, doesn't exceed 90ml.
SMOKING
Started smoking beedis, one a day, 10 years ago.
Stopped 4 years ago when he went into a hypoglycemic episode, but has resumed one year ago.
FAMILY HISTORY:
No similar history in family.
GENERAL EXAMINATION
Patient is examined in a well lit room after taking informed consent.
Patient is conscious, COHERENT and cooperative.
He is moderately built and moderately nourished.
Pallor: Present
Icterus: absent
Cyanosis: absent
Clubbing: absent
Generalized Lymphadenopathy: absent
Edema: Absent
Vitals:
TEMPERATURE AFEBRILE
Blood Pressure: 124/72 mmHg
RESPIRATORY RATE 17 CPM
PULSE RATE 70 BPM
CRANIAL NERVE EXAMINATION
4a) HIGHER MENTAL FUNCTIONS
conscious
• oriented to person and place
• memory - able to recognize their family members and recall recent events
• Speech - no deficit
4b) CRANIAL NERVE EXAMINATION:
I- Olfactory nerve- sense of smell present
II- Optic nerve- direct and indirect light reflex present
III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis
V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.
VII- Facial nerve- face is symmetrical, unable to do forehead wrinkling, left nasolabial fold prominent than right.
VIII- Vestibulocochlear nerve- no hearing loss
IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised
XI- Accessory nerve- sternocleidomastoid contraction present
XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue
MOTOR SYSTEM
ATTITUDE - right lower limb flexed at knee joint
REFLEXES
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee 2+ 2+
Ankle 2+ 2+
SUPERFICIAL reflexes and DEEP reflexes are PRESENT , NORMAL
MUSCLES POWER:
RIGHT LEFT
UPPER LIMB
ELBOW - Flexor 5/5 5/5
- extensor 5/5 5/5
WRIST - Flexor 5/5 5/5
- extensor 5/5 5/5
HAND GRIP 5/5 5/5
LOWER LIMB
HIP - Flexors 5/5 5/5
- extensors 5/5 5/5
KNEE - Flexors 5/5 5/5
- Extensors 5/5 5/5
ANKLE - DF 5/5 5/5
- PF 5/5 5/5
EHL 5/5 5/5
FHL 5/5 5/5
Right Left
BULK
Arm
Forearm 19cm 19cm
Thigh 42cm. 42cm
Leg 28cm. 28cm
TONE
Upper limbs N N
Lower limbs N N
Gait is normal
No involuntary movement
SENSORY SYSTEM - all sensations ( pain, touch, temperature, position, vibration sense) are normal
ATTITUDE - right lower limb flexed at knee joint
TONE - Normal on right side
Normal tone on left side
Bulk - Rt Lt.
Arm: cm cm
Forearm 19cm 19cm
Thigh 42 cm 42cm
Leg 28cm 28cm
CARDIOVASCULAR SYSTEM:
S1 S2 heard, no murmurs
RESPIRATORY SYSTEM:
Bilateral air entry present, normal vesicular breath sounds, no added sounds
GASTROINTESTINAL SYSTEM:
Soft, non-tender, no organomegaly
INVESTIGATION
ECG
TREATMENT
on day 1
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) 2 amp KCL in 500ml NS slowly over 4-5 hrs
On day 2
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) proteolytic enema
8) syrup cremaffine
9) tab spironolactone
On day 3
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) proteolytic enema
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet
On day 4
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) tab ultracet QID
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet
On day 5
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) tab ultracet 1/2 po/ QID
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet
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