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