27 years old male inability to walk






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

I am Nithin Reddy (Roll no 178) of 8th Sem MBBS.


A 27yr old male, lorry driver by occupation, R/O Narketpally came to OPD  with c/o inability to walk since 3 days. 


HISTORY OF PRESENT ILLNESS:                                                    

Patient was apparently asymptomatic 3 days ago then he found himself unable to walk suddenly. It was sudden in onset, gradually progressive. Patient was not able to comb his hair, unbutton his shirt.

No H/O Trauma, LOC, Seizures, head injury. Patient is not able to walk without support since 3 days. No H/O urinary incontinence present.

No H/O bowel and bladder incontinence

His daily routine is waking up at 6: 00 am, drinks tea at 7:00 am, breakfast as rice and curry at 8:00 am and leaves for work. He used to have his lunch as rice and curry  at 1: 00 pm and return to home by 5:00pm. He usually haves his dinner as rice and curry at 8:00pm and goes to bed by 10:00 pm.


HISTORY OF PAST ILLNESS:  

N/K/C/O DM, HTN, TB, Asthma, CAD, CVD

H/O Chyluria 14 months back.


NO SURGICAL HISTORY


FAMILY HISTORY: 

N/K/C/O DM, HTN, TB, Asthma, Epilepsy, CAD, CVD


PERSONAL HISTORY:

Diet: Vegetarian

Appetite: Normal

Sleep: adequate

Bowel and bladder movements: Regular

Addictions: No

Allergies: no known


GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative to time, place and person.

Ht: 170 cm    Wt: 78kg

No signs of pallor,

no icterus, 

no clubbing, 

no cyanosis, 

no koilonychia, 

no lymphadenopathy, 

no edema

vitals: temp: afebrile

BP: 110/80 mmHg

HR: 78 bpm

RR: 18cpm

SpO2: 99%


SYSTEMIC EXAMINATION:

CNS:  LS SPINE. Tenderness over L5 region 

Limb examination:


CNS:conscious
normal speech
no neck stiffness
kernig's sign negative
cranial nerves - intact
motor - intact 
sensory- intact
glassgow score: 15/15

CVS: S1 S2 heard
No thrills
no murmurs

RS: no dyspnoea
no wheeze
trachea central
NVBS+

ABDOMEN: shape of abdomen: scaphoid
no tenderness
no palpable mass
normal hernial orifices
no free fluid
no bruits
liver & spleen not palpable

Gait: normal
musculoskeletal system: normal
skin: normal

INVESTIGATIONS:

RFT: decreased creatinine

LFT: increased Alkaline phosphatase


CUE:

ESR:

CBP: increased lymphocytes

CRP:

Blood sugar random:



REPORTS before 14 months when patient was diagnosed with chyluria(curdy white urine)

USG:

USG, 2D ECHO , MRI findings:

MRI DORSAL SPINE:

USG INTERPRETATION:

MRI LUMBAR SPINE:

MRI CERVICAL SPINE:

Curdy white urine produced 14 months back for 2 yrs due to lymphoureteric connection



hemogram:

Ophthalmic referral:

PROVISIONAL DIAGNOSIS:
QUADRIPARESIS under evaluation (resolving)
? CIDS
CHYLURIA 2° to lymphoureteric connection

 

MANAGEMENT:

DAY 1 
1) T.HIFENAC-P  PO/BD
2)T. PAN 40MG PO/BD
3)T. NEUROKIND LC PO/BD
4) T. GABANTIN 100MG PO/OD

DAY 4
1)TAB. VITCOFOL PO/OD
2) TAB. MVT PO/OD
3)TAB. ULTRACET PO/QID
4)MONITOR VITALS




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