A 32yo with Lower Limb Weakness and Pain

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 CHIEF COMPLAINTS:

A 32yr old gentleman came to the OPD with chief complaints of:

  • B/L Lower limb weakness (Left > Right)
  • B/L Lower limb pain

HISTORY OF PRESENT ILLNESS:

  • Patient was apparently asymptomatic 3 days backs.
  • H/o heavy weight bearing. He developed Left lower limb pain which was insidious in onset, gradually progressive and dragging type
  • No h/o trauma
  • No swellings noted

HISTORY OF PAST ILLNESS:

N/K/C/O DM/HTN/Thyroid disorders

TREATMENT HISTORY:

Not significant

PERSONAL HISTORY:

  • Married
  • Appetite: Normal
  • Diet: Mixed
  • Bowels: regular
  • Micturition: Normal
  • No known allergies
  • Habits/Addictions: Regular alcohol and tobacco consumption

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

  • No Pallor
  • No Icterus
  • No Cyanosis 
  • No Koilonychyia
  • No Clubbing
  • No Lymphadenopathy
  • No Edema

VITALS:

  • BP: 110/70 mmHg
  • PR: 80 bpm
  • RR: 16 cpm
  • Temp: Afebrile
  • SpO2: 96%  @ RA

SYSTEMIC EXAMINATION:

CVS:

  • S1,S2 heard
  • No murmurs
  • No thrills

Respiratory System:

  • Position of trachea: Central
  • Breath sounds: Vesicular
  • Adventitious sounds: None
  • No dyspnea and wheeze

Abdomen:

  • Shape: Scaphoid/Obese
  • Bowel sounds: Heard
  • No palpable masses or tenderness

CNS:

  •   Conscious
  •   Normal speech
  •   No signs of Meningeal irritation

TONE

RIGHT

LEFT

UL

Normal

Normal

LL

Normal

Normal


POWER

RIGHT

LEFT

UL

5/5

5/5

LL

4/5

4/5

Cerebral Signs:
  • Finger-nose not in coordination
  • Knee-heel not in coordination

PROVISIONAL DIAGNOSIS:

Peripheral Neuropathy 2° to Alcoholism / Myalgia

INVESTIGATIONS:

1. CBP:


2. Blood Urea:



3. Blood Sugar - Random:


4. Serum Electrolytes:


5. CUE:



6. Serum Creatinine:


7. CXR

8. ECG:


9. Doppler 2D Echo:


7. X-Ray Left Hip Joint AP/LAT




PLAN OF CARE:

Conservative

TREATMENT:

21/6/21:

1. Inj. THIAMINE 200mg in 100ml NS/IV/TID [1 - 1 - 1]

2. Inj. OPTINEURON lamp in 100ml NS/IV/OD [x - 1 - x]

3. Inj. TRAMADOL lamp in 100ml NS/IV/BD [1 - x - 1]

4. BP/PR/Temp SPO2 monitoring

5. GRBs charting

6. Tab. HIFENAC-MR BD [1 - x - 1]

22/6/21, 8:00 am:

1. Inj. THIAMINE 200mg in 100ml NS/IV/TID [1 - 1 - 1]

2. Inj. OPTINEURON lamp in 100ml NS/IV/OD [x - 1 - x]

3. Inj. TRAMADOL lamp in 100ml NS/IV/BD [1 - x - 1]

4. Tab. HIFENAC-MR PO/BD

5. BP/PR/Temp SPO2 monitoring

6. I/O charting

23/6/21:

1. Inj. THIAMINE lamp in 100ml NS/IV/TID [1 - 1 - 1]

2. Inj. OPTINEURON lamp in 100ml NS/IV/OD [x - 1 - x]

3. Tab. HIFENAC-MR BD [1 - x - 1]

4. Oint. DICLOFENAC-R/A TID

5. BP/PR/Temp SPO2 monitoring

6. GRBs- 12th hourly

24/6/21:

1. Inj. THIAMINE lamp in 100ml NS/IV/TID [1 - 1 - 1]

2. Inj. OPTINEURON lamp in 100ml NS/IV/OD [x - 1 - x]

3. Tab. HIFENAC-MR BD [1 - x - 1]

4. Oint. DICLOFENAC-L/A TID

5. BP/PR/Temp SPO2 monitoring

6. GRBs- 12th hourly

7. Inj. TRAMADOL lamp in 100ml NS/IV/TID [1 - 1 - 1]

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