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70 M PARAPERISIS

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Patient came with the 
C/o generalized weakness of lower limbs since 3 months 

HOPI
Pt was apparently asymptomatic till 3 months back then he had a h/o slip and fall following which he used to walk with support.1 week ago he had h/o fall again following which he is unable to walk since then 
No h/o giddiness,LOC, head injury
No history of involuntary movements
Tingling sensation present in bilateral toes of lower limbs

PAST HISTORY 
K/c/o HTN since 20 years on tab ramilpril
K/c/o DM since 20 years on tab glimi M1 po/of
N/k/c/o CVA CAD TB EPILEPSY

PERSONAL HISTORY 
diet: mixed
appettite:normal
bowel and bladder: regular
sleep: adequate
no addictions

GENERAL EXAMINATION 
patient is conscious,coherent, cooperative,well oriented to time, place,person
moderatly built and nourished
Vitals-
temperature-afebrile
pr-66bpm
bp-120/80 mmhg
rr-18cpm

SYSTEMIC EXAMINATION 
CVS -s1s2 heard,no murmurs
RS-bae+,nvbs heard
P/A-soft,non tender,no organomegaly
CNS 
On examination 
Spinal tenderness present T12 to L1
SENSORY EXAMINATION
SPINOTHALAMIC   

                                          R. L
CRUDE TOUCH PRESENT PRESENT 
PAIN PAIN BELOW ANKLE PAIN SENSATION ONLY IN ANKLE
TEMP. ABSENT. ABSENT
POSTERIOR COLUMN
FINE TOUCH ABSENT. ABSENT
VIBRATION 
STYLOID ABSENT. ABSENT
SHAFT ABSNET ABSENT
MEDIAL MALLEOLI. AB. AB
JOINT POSITION. 7/10. 7/10
CORTICAL COLOUMN 
TACTILE LOCALISTION. + +

MOTOR EXAMINATION OF LOWER LIMB
1)ILLIOPSOAS. 3/5. 3/5
2)ADDUCTOR FEMORIS. 3/5. 3/5
3)GLUTEU MEDIUS & MINIMUS. 4/5 4/5 
4)GLUTEUS MAXIMUS. 3/5. 3/5

1) HAMSTRING 4/5 4/5
2)QUADRICEPS FEMORIS 5/5 5/5

1) TIBIALIS ANTICUS. 4/5 4/5
2)TIBIALIS POSTICUS. 4/5 4/5
3)PERONEI. 4/5 4/5
4)GASTRONEMIUS. 4/5. 4/5
5)EXTENSOR DIGITORUM. 4/5. 4/5
6)FLEXOR DIGITORUM. 4/5. 4/5
7)EXTENSOR HALLUCIS LONGUS 4/5 /5
8)DIGITORIM BREVIS. 4/5. 4/5

IMPRESSION - ASYMMETRICAL SENSORY LOSS SECONDARY TO DIABETES

MOTOR EXAMINATION OF UPPER LIMB
MUSCLES OF SHOULDER GIRDLE
1)DELTOID . 4/5. 4/5
2)SUPRASPINATUS. 4/5. 4/5
3)INFRASPINATUS . 4/5 4/5 
4)RHOMBOIDS 3/5. 3/5
5)SERRATUS ANT . 4/5. 4/5
6)PECTORALIS MAJOR. 4/5. 4/5
7)LATTISMUS DORSI . 4/5 4/5 

MUSCLES OF ELBOW JOINT
1) BICEPS. 4/5 4/5
2)BRACHIORADIALIS. 4/5 4/5
3)TRICEPS 4/5 4/5

FOREARM AND WRIST JOINT
1) EXT CARPI RADIALIS . 4/5. 4/5
2) EXT. CARPI ULNARIS 4/5. 4/5
3)EXTENSOR DIGITORUM . 4/5 4/5 
4) FLEXOR CARPI RADIALIS 4/5 4/5
5) FLEXOR CARPI ULNARIS 4/5 4/5
 
MUSCLES OF THUMB
1)ADDUCTOR POLLICIS LONGUS 
4/5 4/5
2)ADDUCTOR POLLICUS BREVIS
 4/5 4/5
3)EXTENSORPOLLICUS LONGUS 
4/5. 4/5 
4)OPPONENS POLLICIS 4/5 4/5 
5)ABDUCTOR POLLICIS BREVIS 4/5 4/5
6) FLEXOR POLLICUS LONGUS. 4/5. 4/5
7) ADDUCTOR POLLICUS

MUSCLES OF HANDS AND FINGERS
1) FIRST DORSAL INTEROSSEUS AND PALMAR INTEROSSEOUS 4/5. 4/5
2)FLEXOR DIGITORUM SUBLIMUS
 4/5 4/5
3) FLEXOR DIGITORUM PROFUNDUS
      4/5 4/5 
4) ABDUCTOR DIGITI MINIMI. 4/5 4/5

REFLEXES 

               Rt Lt
B + +
T + +
S. + +
K. +++ +++
A. + +
P. Extension. Flexion


OPTHALMOLOGY REFERRAL I/V/O DIABTIC AND HYPERTENSIVE RETINOPATHY
 IMPRESSION- NO CHANGES OF HYPERTENSIVE OR DIABETIC RETINOPATHY NOTED

ORTHOPEDICS REFFERRAL IN VEIW OF GLUTEAL ABSCESS SECINDARY TO IM INJECTION 
IMPRESSION - NO ACTIVE SURGICAL INTERVENTION NEEDED

PROVISIONAL DIAGNOSIS
QUADRIPARESIS UNDER EVALUATION ( COMPRESSIVE MYELOPATHY L1 -L3 ; C5-C3
WITH PERIPHERAL NEUROPATHY (SENSORY ASYMMETRICAL SECONDARY TO DIABETES MELLITUS TYPE 2)
WITH K/C/O HYPERTENSION AND DIABETES MELLITUS TYPE 2 SINCE 20 YEARS

INVESTIGATIONS

TREATMENT
1) TAB.ULTRACET 1/2 TAB PO/OD/QID
2)TAB. SHELCAL 500 MG PO/OD
3)TAB.GLIMI M1 PO/OD AT 8AM BEFORE FOOD
4)RAMIPRIL 2.5 MG PO/OD

ADVICE AT DISCHARGE.
1) TAB.ULTRACET 1/2 TAB PO/OD/QID
2)TAB. SHELCAL 500 MG PO/OD
3)TAB.GLIMI M1 PO/OD AT 8AM BEFORE FOOD
4)RAMIPRIL 2.5 MG PO/OD

FOLLOW UP
review to general medicine OPD in 1 week



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