Hello everyone! Iam an intern in the medicine department one of the important terms of getting the internship completion is to complete my log book with my daily log what i learn during the course of my duties.

Case presentation:
      A 23 year old male autodriver by occupation came with cheif complaint of muscle pain of both biceps and calves after lifting heavy weights since 1month.

HOPI:

Patient was apparently asymptomatic 1month back , then he developed muscle pain after lifting heavy weights  , which is of dragging type and associated with tingling sensation of both upper limbs. and lower limbs extending upto midarm , migthigh and slightly above the umbilicus.
-Difficulty in carring heavy weights for long distance due to pain.
-Difficulty culty in getting up from squatting and sitting position.
-Pain on lifting the arms above the shoulders.
-Headache intermittently on exposure to the sunlight  for long time.
-Slippage of footwear and taking more time in wearing slippers, able to feel the slippers.
-Able to differentiate between hot and cold, able to feel the clothes.
-Able to perceive pain sensation on pinching the skin patient feel the burning sensation.
-Able to mix the food , comb hair , hold things tightly , button and unbutton the shirt, feel the ground and washbasin attacks.
 No history of giddiness, vertigo, tinnitus, diplopia, deviation of mouth, slurring of speech,
band like sensation, dysphagia,buckling,  stiffness, hearing difficulties , loss of taste and smell perception.
No history of fever, diarrhoea, bowel and bladder disturbances.

Past history:
No similar complaints in the past.
Patient is not a known case of HTN, DM , epilepsy, asthma,CKD,CAD,TB.

Drug history:
Not allergic to any known drugs.

Family history:
No similar complaints in the family.

Personal history:
 Diet: mixed
 Appetite: normal
 Sleep: adequate
Bowel and Bladder : no disturbances
Addictions:  taking toddy daily twice 1-2litres since 1 month.

GENERAL EXAMINATION:
Patient is conscious,coherent, cooperative, well built and well nourished.

VITALS:
Temperature: afebrile
BP: 110/70 mm of Hg measured in the right arm in the sitting position.
PR: 92 beats per minute
RR: 26 cycles per min
 Sp O 2 : 97% on room air.
GRBS : 108 mg/dl.

No signs of pallor , icterus, cyanosis,clubbing, koilonychia, lymphadenopathy,Oedema

Respiratory System Examination:
No dyspnea, wheeze,
Breathsounds- vesicular
No added breath sounds

CVS examination:
 S1 and S2 heard
No added murmurs

Per abdomen examination:
 Abdomen: scaphoid,soft
 No tenderness, local rise of temperature,
 Hernial orifices : free
 Bowel sounds-sluggish

CNS examination:
 Higher mental functions- conscious,coherent ,oriented to time,place, person .
 Memory-intact short term and long term
 Recall- intact
 Calculation: attention
 Speech- spontaneous with intact comprehension ,naming, reading ,writing. , fluency
Gait: normal
Cranial nerves : intact

Motor system:                     Right.                    Left
         Bulk    :      UL          41.                           41
                            LL         35.                             35
          Tone :      UL            N.                             N
                           LL            N.                              N
       Power::
Shoulder- supraspinatus—— 5/5.                5/5
                  Deltoid—————   5/5.                 5/5
                 Infraspinatus———5/5.                 5/5
                 Pectoaralis major   5/5.               5/5
                 Rhomboid.            5/5.                  5/5
              Serratus anterior.     5/5.                 5/5
             Lattismus dorsi——  5/5                    5/5
Elbow:  biceps
              Triceps                   5/5.                        5/5
             Brachioradialis
             
Forearm and wrist:
                ECRL
                 ECU.                5/5                            5/5
                 ED
                 FCR
                  FCU
Thumb : Epl,Epb, Fpl—— 5/5.                          5/5
Hands:   Lumbricals
               Inteeossesi        5/5.                          5/5
 Trunk muscles:
             Entensor of spine
              Intercostals.          N.                             N
              Abdominalis
Lower limbs::
      Ilioposas —————-  5/5.                          5/5
      Adductor femoris—— 4/5                         4/5
       Gluteus maximus ,
        Medius, Mininmus  4/5.                          4/5
Thigh and knee:
  Hamstrings—————— 4/5.                           4/5
  Quadriceps——————  5/5.                           5/5
Lower leg and ankle :
    Tibialis anterior———— 5/5.                          5/5
     Tibialis posterior———5/5.                            5/5
Peronei and gastrocnemius 5/5.                        5/5
 Foot:
  Extensor digitorum—— 3/5.                               3/5
   Flexor DL —————-      5/5.                              5/5
   EHL————————         3/5.                             3/5
 Reflexes:                          Right.         Left
     Biceps——.                       -                -
     Triceps —-                         -                -    
     Supinator—-                      -                -
     Knee———-                   +1.               +1
   Ankle                                 -                    -
Plantar                            mute                   mute

SENSORY        Rt                    Lt
  pain                N                     N 
Touch               N                     N
Temperature   N                     N 
Vibration -UL   N                    N
                 -LL decreased    decreased 
Stereognosis    N                    N
Graphesthesia - impaired   impaired
Tactile discrimination- N        N
Two ponit discrimination-✓      ✓
CEREBELLUM:
 Nystagmus             -                    -
Scanning&speech    -                  - 
Hypotonia                  -                   -
Dysdiadochokinesia   -              -
Finger nose test        -                -
Heel sheen test         -               -
Investigations are:
RFT
LFT
HEMOGRAM
CUE
CK





EXAMINATION :
  


Diagnosis: 
Alcohol induced peripheral neuropathy.

Treatment:
Tab. Neurobion forte /po/OD for 1 month
Tab. Pregabalin 75mg/po/HS for 2 weeks
Avoid alcohol.


Comments

Post a Comment

Popular posts from this blog

"The Darting Tongue in Sydenham's Chorea."

Image
 Hello everyone, This is R Preethi  an intern in the medicine department,  An internship is a hands -on way to learn new skills. Completing an internship can expose you to the workplace, letting you know what really goes on . One of the important terms of getting the internship  completion  is to complete my log book by documenting the cases I saw, along with my daily log .  The case  presentation:  A 17 year old lady from jaggayapet, presented with a 1 week history of "shaking". Hailing from an impoverished family,  she was apparently asymptomatic 2 years ago, when she first developed  wheezing and breathlessness on a cold winter night at 1am which woke her up from her sleep. The mother reported that it resolved spontaneously over a short period of time . At this point ,she denied a history  of sweating or palpitations.  She also  denied a prior history of chest tightness and exertional dyspnea.   5 days later she  started developing cough and breathlessness with very little
Read more

A Middle aged Male with CKD, CLD, ?Ascites, ?Sob .

        A 46 year old male who is a farmer presented to the casualty in the midnight with complaints of shortness of breath since 1 day which started in the early morning around 4:00am which woke him from his sleep , abdominal distention with decreased urine output since 3 days ,was taken to the outside hospital and referred to our center. He complained that , this “ayasam” didn’t let him rest for a second .  He gave a history of similar complaints in the past with intermittent attacks of shortness of breath ,fever associated with chills and was rushed to the hospital during midnights , those episodes lasts for 1-2 days got subsided with treatment , was told that his hb :9.5 gm/dl causing his sob. He gave a clear history that every episode made him very uncomfortable to sleep , he used to go near the windows /out of the house to catch the fresh air.  He gave a history of abdominal discomfort with abdominal distention and decreased appetite since 3 days ,didn’t pass stools since 3 days,
Read more