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6/12 /2022
A 60 year old male electrician by occupation, resident of nalgonda district , came to casualty at 3.00 pm on 5th December.
CHIEF COMPLAINTS:-
Tingling and numbness of both upper and lower limbs since 5 year
Headache and vertigo from 1year.
Generalized weakness of lower limbs since 5 days.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 10 years back then he got electric shock during his work on the right leg above knee.
Then he went to local RMP and was given unknown medication.
Then 5 years after that incident , he complained of tingling and numbness in the right leg .
3 years back his family members noticed that he was speaking nonrelevant speech and was unable to talk, also had blurring of vision for which they went to hospital and they were said that there was some clot in the brain.
2 years back he also had history of paralysis.
1 year back he started having headache which is associated with vertigo which is insidious in onset and gradually progressive relieved on medication.
18 months back he developed tingling and numbness in the left leg and later he also started developing numbness and tingling in both palms.
5 days back he complained of weakness of
Lowerlimb.
There was no sensations present in both lower limbs.
No deviation of mouth, difficulty in swallowing
PAST HISTORY:-
Known case of Diabetes since 4 years and is on medication metformin + glimeperide
History of CVA
Not a Known case of hypertension, asthma, TB, epilepsy.
Not a Known case of CAD.
PERSONAL HISTORY-
Appetite:-normal
Bowel and bladder :regular
Diet:mixed
Sleep:adequate.
Addictions:
Daily intake of alcohol of 90 ml since 15 years
Cigarette 1 packdaily since 10 years
Allergies:-nil
Family history:no significant family history.
GENERAL EXAMINATION:-
Patient is conscious, coherent, cooperative and well oriented to time , place and person, moderately built and moderately nourished.
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema.
Vitals :-
Temperature:- afebrile
RR:-17cpm
BP:-130/80 mm/hg
HR:- 110bpm
SYSTEMIC EXAMINATION:-
CNS:-
Higher mental functions intact.
Gait:- normal CRANIAL NERVES: INTACT
Power
Rt UL-5/5. Lt UL-5/5
Rt LL-4/5. Lt LL-4/5
Tone-
Rt UL -N,Lt UL-N
Rt LL-N,Lt LL-N
Reflexes:. RIGHT LEFT
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee. -- --
Ankle:- -- --
SENSORY:
crude touch normal in upper limbs, decreased in lower limbs.
Fine touch :- + +
Pain N N
Temperature N N
Vibration:- not felt
Joint position:negative.
Stereognosis:negative.
Romberg test:-positive (falling on right side).
Cerebellum functions:-
Finger finger test:-+
Finger nose test:-+
Dysdiadokinesia:-not present.
Heel knee test:- negative
Straight leg walking test:-positive.
ABDOMINAL EXAMINATION:-
•Inspection :- no scars
•Palpation :- soft,non tender.
CVS:S1,S2 heard,no murmur
RESPIRATORY SYSTEM:
trachea central in position
Normal vesicular breath sounds heard
BAE ++
INVESTIGATIONS:
HEMOGRAM:
Urine examination:
Serum electrolytes:
Blood sugar:
Liver function test:
X-ray
ECG:
USG
2D echo
Provisional diagnosis:-
Diabetes mellitus with Peripheral neuropathy.
medical treatment:-..
• glycomet gp
• vertin 16mg.
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