A 45 YEAR OLD MALE NOT BEING ABLE TO WALK SINCE 2 DAYS

29.03.23

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CHIEF COMPLAINS :

A 45 years old male,daily wage worker, came to opd with the cheif complaints of not being able to walk since 2 days 

>generalised weekness since 2 months

HOPI:

Patient was apparently assymptomatic 2 months back then he developed generalised weakness which was sudden in onset and progressive. he is not able to walk since 2 days He was Irregular to work(due to generalised weaknesses and loss of hearing since 16 years) but used to walk without support .

PAST HISTORY:

H/o fall from tree, due to slippage at age of 12 years -- developed hearing loss and tinnitus since then 

Developed swelling of scrotum and low backache 4 years ago and underwent surgery for hydrocele, and diagnosed to be having diabetes since 4 years (not used any medication)

6 months ago developed scaly hyperpigmented papules -itchy lesions initially developed in bilateral lower limbs and then spread upwards and involved bilateral lower buttocks and lower abdomen (acquired from his wife)

C/o hard stools associated with bleeding per rectum  since 2 months

2 months back h/o outside food intake , developed vomiting (for 1 day) and developed gradually progressive, weakness of both lower limbs (associated with decreased sensation of lower limbs and upper limbs)

K/c/o diabetes since 4 years (not on any medication

N/k/c/o diabetes, hypertension, TB, ba, epilepsy, thyroid

H/o hydrocele surgery 4 years ago

PERSONAL HISTORY:

 labourer by occupation

Habits: smoker: 30 years ago

General physical examination:

Patient is c/c/c

No signs of pallor icterus cyanosis clubbing genralised lymphadenopathy and pedal edema

Temp: afebrile

Pr: 86bpm

RR: 14 cpm

BP: 110/70mmhg

GRBS:172mg/dl

 

Systemic examination:

Cvs: s1 and s2 heard. No murmurs

Rs: b/l ae present. Nvbs 

P/a: soft. Non tender

CNS: 

            UPPER LIMB   LOWER LIMB

TONE    

 RIGHT        HYPO.                N

LEFT.           HYPO.            HYPO

POWER

RIGHT.           4/5.             2/5

LEFT.              4/5.              2/5

REFLEXES:.       RIGHT.      LEFT

BICEPS.              --                --

TRICEPS            --                --

SUPINATOR.     --                --

KNEE.                --                --

ANKLE.             --                --

PLANTAR.      Mute.        Mute

INVESTIGATIONS:

Rx:

1. INJ. OPTINEURON IN 500 ML ND IV/OD

2. TAB. GABA NT 100/10 MG PO/H/S

3. TAB. RANTAC 150 MG PO/OD

4. PHYSIOTHERAPY OF UPPER LIMB AND LOWER LIMB