48/M WITH EQUINE GAIT PARAPARESIS 2 MONTHS HBV+

 UNIT 1 


MEDICAL WARD 


DOA:04/06/23


A 48 year old male farmer by occupation,resident of Nalgonda 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 diabetes, thyroid,epilepsy,asthma,CAD CVA




PERSONEL HISTORY: 


Diet:mixed


Sleep:regular 


Appetite: Normal 


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 well built and moderately nourish


Pallor present 


Icterus: Absent 


Cyanosis: Absent 


Clubbing: Absent 


Lymphadenopathy: absent









Vitals::


Afebrile 


PR- 94bpm


BP- 100/90mmHg 


 RR- 14cpm 




CVS: s1,s2 heard ,no Murmurs, 


RS:BAE+ ,no added sounds ,NVBS,  


P/A: soft, non tender


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 Daignosis: ? Chronic inflammatory Demyelinating polyneuropathy 


 


Investigations:






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 40 mg PO/OD

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