Pt with quadriparasis

 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 a series of inputs from an 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 in the comment box is welcome
 
42 year old male came to the opd with 
CHEIF COMPLAINTS OF - 
•complete weakness of both lower limbs
•partial weakness of both upper limbs 

HISTORY OF PRESENTING ILLNESS
• patient was apparently asymptomatic 4 days back , the he suddenly fell down due to weakness of both lower limbs at Ganesh nimarjanam ( dancing and took alcohol at that time)  and it was progressing gradually 
He is unable to walk and cannot sit on his own 
• weakness of upper limbs improved to some extent since 2 days 
Unable to mix food and hold objects 
•No tingling and numbness in upper limbs ,but numbness is present in lower limbs 
 •No history of headache , seizures , vomitings
 •No deviation of mouth is seen 

PAST HISTORY


PERSONAL HISTORY
Sleep 
Bowel and bladder
Appetite
Alcoholic from last 20 yrs 
Smoker


FAMILY HISTORY  : Insignificant

GENERAL EXAMINATION : 
Patient was examined after informed consent
He was conscious, coherent and co operative
No Cyanosis ,
No clubbing
No pallor
No Icterus 
No lymphedenopathy
Edema over both foot 

VITALS :
BP :110/80
PULSE :75
RR : 14 cycles per minute
TEMPERATURE : Afebrile

SYSTEMIC EXAMINATION : 
CVS : S1 S2 Heard
RS : BAE + 
ABDOMEN EXAMINATION- no tenderness seen, no palpable mass seen, not distended
 CNS EXAMINATION
  ▪ sensory examination,- touch, pain , vibration present
  ▪ 

MOTOR SYSTEM :
                                              Right.         Left
 

Bulk:    inspection    UL      normal         normal
                                    LL.     normal         normal

             palpation.       UL     Normal       normal
                                    LL.      Normal.     normal



Tone:               UL            normal.         Normal
                         LL.          hypotonia    Hypotonia

Power              UL.            4/5              4/5
                         LL             0/5.              0/5

  
Reflexes.  
   Superficial reflexes
                       Right.           Left
Corneal.            P                  P
Conjunctival    P.                  P
Abdominal.      +               +
Plantar            flexor        flexor



    Deep tendon reflexes 
                     Right.             Left
Biceps jerk.          +                     +
Triceps jerk .         +                   +
Supinator jerk.     +                    +
Knee jerk                lost              lost
Ankle jerk            lost                  lost




INVESTIGATIONS : 
Day 1 


MRI :

2 D  REPORT
ECG 

       
  

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