Hello everyone... I am an intern in medicine department and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties.
CASE DISCUSSION
A 18YEAR OLD MALE PATIENT CAME TO OPD WITH CHIEF COMPLAINT OF WEAKNESS OF B/L LOWERLIMBS SINCE 20 DAYS
THE WEAKNESS STARTED IN PROXIMAL REGION 2 YEARS BACK WHICH IS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE LATER PROGRESSED TO B/L DISTAL REGION
H/O B/L EDEMA OF LL NON PITTING TYPE
H/O DIFFICULTY IN SQUATTING POSITION AND GETTING UP FROM SQUATTING POSITION
H/O DIFFICULTY IN WEARING AND HOLDING CHAPPALS
NO H/O DIFFICULTY IN COMBING HAIR , BUTTONING AND UNBUTTONING SHIRT
NO H/O CRANIAL NERVE INVOLVEMENT
PAST HISTORY
NOT A K/C/O HTN,DM,CVA, EPILEPSY,CAD,TB,THYROID
PERSONAL HISTORY-
diet-mixed
appetite-normal
sleep-adequate
B&B-regular
FAMILY HISTORY-
not significant
-no known food or drug allergies
GENERAL EXAMINATION-
-patient was conscious, coherent and coperative
-moderately built and nourished.
-no signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema
-VITALS
1.temperature-AFEBRILE
2.pulse rate-92bpm
3.respiratory rate-18 cycles/min
4.BP-130/90mmhg
5.SpO2-96%
6.GRBS-142mg/dl
SYSTEMIC EXAMINATION
I.CVS-
S1 S2 heard
no added murmurs
2.RESPIRATORY SYSTEM-
-normal vesicular breath sounds heard
-bilateral air entry present
3.PER ABDOMEN-
shape=scaphoid
umbilicus=central and normal in position
all quadrants moving equally on respiration
no tenderness
no organomegaly
bowel sounds-heard
no bruit heard
4.CNS-
patient is conscious, coherent, coperative
patient well oriented to time, place and person
higher mental functions= normal
Cranial nerves- intact
Motor system-
tone - normal
power - 4-/5 in both lower limbs
reflexes absent in both lower limbs
sensory system-normal
No meningeal signs
No cerebellar signs
Based on the above complaints patients blood samples were sent for
1.CBP
2.serology
3.RFT
4.ECG
5.CUE
6 MUSCLE BIOPSY
DD - Muscular dystrophy
Acute on CIDP
TREATMENT
T Prednisolone 15mg po od
T Pantop 40mg bbf
T Met xl 12.5mg od
Cap Becosules od
T Chymerol forte od
T Taxim 200mg bd
T Vit c od
T Ultracet sos
