General Medicine case of 60 Year Male with weakness of four limbs.

 

60 year old male with sudden onset weakness 

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.


Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.
I have 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.

A 60 year old male patient resident of kattangur farmer +daily wage worker +toddy (palm) tree climber stopped working since  3 months now does routine physical activity at home and  was presented with chief complaints of

Weakness of all four limbs since 5 days

Tingling and numbness over all limbs and weakness all over the the body since 5 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptmatic 5 days back when he developed sudden onset of weakness in his lower limbs 
(friday night) when he got up from sleep and went for using washroom . He was unable to get up and use his lower limbs so he took the support of walls  to walk and after that he had a fall on his limbs which was not associated with any injury.
On friday morning  he also complained of fever subsided by medication.

Weakness was first in the lower limbs and became progressive and involved upper limbs on Saturday morning.But subsequently there was  improvement in upper limb weakness.

He was taken to  local hospital in nakrekal for the management and was given fluids but weakness remained  the same in lower limbs (more in right lower Limb)

He came back home  and on sunday went to Nalgonda hospital and was not satisfied.  His weakness became progressive and was unable to get up and roll over ,unable to raise his arms above shoulders.
Then he came to Narketpally on Wednesday.
H/o Nausea and weakness all over the body..
No h/o trauma
No  h/o loss of consciousness,seizures, Slurring of speech.
No h/o fasiculations
No h/o loss of bladder movements and urinary retention 
No h/o headache, vomitings, visual disturbances., diplopia
No h/o loss of weight and loss of appetite 
No h/o any sensory deficit
He is not taking food because of nausea and bowel habits are irregular.

He  was able to grasp the objects could recollect names and past events and obeyed all commands.

His daily routine includes waking up at around 9am in the morning and does breakfast at 10 /11am  goes back to sleep and will have his lunch around 3 pm.He takes his dinner at 10 pm and goes back to sleep at 11pm



PAST HISTORY:

No H/o similar complaints in the past
Not a known case of Hypertension ,TB,Bronchial Asthma,thyroid, CA and no comorbidities.

TREATMENT HISTORY

Not on any medication

SURGICAL HISTORY:
NO H/O any surgeries in the past

 PERSONAL HISTORY:
Diet: Mixed
Appetite:Decreased
Sleep:Adequate
Bowel and bladder movements:Bowel habits are not regular
Allergies:No
Addictions:Occasional toddy and alcohol drinker. Stopped 

FAMILY HISTORY:
No H/o Similar complaints in the family


PHYSICAL EXAMINATION:
Patient is conscious coherent and cooperative 
Moderately built and moderately nourished 
 Well oriented to time place and person

VITALS 
TEMPERATURE: AFebrile
Pulse rate: 89bpm
BP: 110/80 mmhg
Spo2:99%. At room air

Pallor present 
No icterus 
No cyanosis 
No clubbing 
No lymphadenopathy
No edema

SYSTEMIC EXAMINATION:













He is conscious  coherent and coperative
Speech: Normal
No neck stiffness 
Kerning sign:
Power and tone :

Reflexes:

Biceps:   Right  Left
Triceps:Right  Left
Supinator:Right Left
Knee:Right  Left
Ankle:Right  Left


CVS EXAMINATION:
Cardiac sounds S1 S2 heard
No murmers  heard 

 RESPIRATORY SYSTEM 
Normal vesicular breath sounds heard
Trachea: central
No wheeze
 
ABDOMEN EXAMINATION:
Shape of abdomen: scaphoid
No tenderness 
No palpable mass
Liver not palpable
  
INVESTIGATIONS:
MRI
HEMOGRAM
RFT
RBS
CHEST XRAY 
COMPLETE URINE EXAMINATION 
LIVER FUNCTION TESTS 
ECG


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