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Here is a case i have seen:
62 yr old male came to the opd with c/o of tingling and numbness of both upper and lower limbs since 15 days .
Noticed weakness in both upper and lower limb since 3 to 4 days .
Patient was apparently well 15 days back and developed tingling sensation in left index finger which was insidious in onset and gradually progressive to hand 5 days later tingling and numbness started in right hand which was also insidious in onset and gradually progressive on increasing pattern they went to local medical shop and took some medication on not responding they went to nalgonda government hospital and then to a local rmp . Tingling and numbness progressed to both lower limbs after 2 days on still not responding to it they went to Ayurvedic doctor and later presented to opd with C/o tingling and numbness in b/l upper limbs till MCP joint and upto ankle joint in both lower limbs.
There was a h/ o fall 3 days back on lifting heavy weight and was accompanied by his wife and son.
Past history:-
K/c/o of epilepsy on regular medication since 30 years
Tab . Phenytoin 200 mg OD
Last seizure episode 6 months back
Not a k/c/o of DM , HTN , asthma , TB
Personal history:-
Diet : mixed
Sleep : adequate
Bowel and Bladder : regular
Occasional Alcoholic
On examination:-
Temp: Afebrile
PR : 68bpm, normal volume, regulad
BP : 110/70 mmhg
RR : 22/min
SpO2 99%on RA
CVS : S1 S2 +, NO MURMURS
RS : BAE+, NVBS
P/A : SOFT, NON TENDER
CNS :
orientated to time, place, person
Speech normal
Memory immediate+, recall+, recent+
Motor
Bulk normal
Tone increased in both upper and lower limbs
Power R. L
Upper limb. 3/5. 3/5
Lower limb. - 4/5. - 4/5
Reflexes B T. S. K. A. Plantar
UL. 3+. 3+. 3+. 3+ 2+. Mute.
LL. 3+. 3+. 3+. 3+ 2+. Mute
Pectoral reflex right 2+
Left 3+
Scapular reflex right 2+
Left 3+
Jaw jerk absent
Superficial:
Corneal presentConjunctival present
SENSORY
Posterior column
Proprioception right upper limb +
Lower limb -
Left upper limb -
Lower limb -
Vibration sense lost in upper and lower limbs
Sternal present
Mastoid present
Anterior spinothalamic tract
Pain. Upper limb absent upto wrist on both sides
Lower limb absent upto knee on both sides
Crude touch upper limb absent upto wrist on both sides
Lower limb absent upto ankle
Cortical stereognosis+
Cerebellum:
No finger nose in coordination
No finger finger incoordination
Dysdiadokinesia absent
Investigations:
Hb - 11.5
Tlc- 8500
Plt -2.22
Rbs- 89
RFT:
Urea - 26, creat-1.0 uric acid -2.5,ca-10.1 ,Na-138, K -4.0 ,Cl-101
LFT ON 28/09
TB-0.44, DB-0.20,ALP-145 ,SGOT -18 ,
SGPT -16 , Alb-4.0 ,A/G - 1.41
Cue-
Puscells-2-3
Albumin - nil
Sugar - nil
MRI BRAIN
MRI CERVICAL SPINE
Xray
Ecg
USG abdomen
Treatment :
1.inj optineuron 1amp in 100ml NS/IV/OD
2.inj pantop 40mg /IV/OD
3.BP /PR/SPO2 charting 6th hourly
4.GRBS charting 8th hourly
5.tab pregabalin 75mg H/S
6.tab eptoin 100mg /PO/OD
On examination:
Temp: Afebrile
PR : 68bpm, normal volume, regulad
BP : 110/70 mmhg
RR : 22/min
SpO2 99%on RA
CVS : S1 S2 +, NO MURMURS
RS : BAE+, NVBS
P/A : SOFT, NON TENDER
CNS :orientated to time, place, person
Speech normal
Memory immediate+, recall+, recent+
Motor
Bulk normal
Tone increased in both upper and lower limbs
Power R. L
Upper limb. 3/5. 3/5
Lower limb. - 4/5. - 4/5
Reflexes B T. S. K. A. Plantar
UL. 3+. 3+. 3+. 3+ 2+. Mute.
LL. 3+. 3+. 3+. 3+ 2+. Mute
Pectoral reflex right 2+
Left 3+
Scapular reflex right 2+
Left 3+
Jaw jerk absent
Superficial: Corneal prsent
Conjunctival present
SENSORY
Posterior column
Proprioception right upper limb +
Lower limb -
Left upper limb -
Lower limb -
Vibration sense lost in upper and lower limbs
Sternal present
Mastoid present
Anterior spinothalamic tract
Pain. Upper limb absent upto wrist on both sides
Lower limb absent upto knee on both sides
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