GENERAL MEDICINE CASE DISCUSSION

 45 years old female with Paraparesis secondary to trauma a/w dysphagia since 15days.

June 1, 2023

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CASE:-

  A 45yr old female who is a Mandala Officer by occupation resident of chityal came  to  ENT OPD with chief  complaints of   

C/O Generalized weakness of lower limbs since 10 years

Difficulty in swallowing since 15 days 

HOPI:

Pt was apparently asymptomatic till 1999  then she delivered a baby(by c-section due to cord entanglement)  she also stated that she started  developed Generalized weakness ( due to low haemoglobin levels ) not associated with pain and was able to perform her daily activities

Her husband also left as she couldn't perform her daily activities.Her son currently stays in the hostel 

 She previously used to work as mandal officer.

And in 2012 she stopped going to work because she started developing weakness  insidious in onset , gradually progressive , associated with pain , Aggrevated with walking and relieved with rest. she could not walk for long distances and she managed to  to perform  daily activities

In 2023 Jan she alleged had h/o slippage in bathroom following which she was normal for 5 days 

Next day she couldn't get up from bed which is sudden in onset and non progressive and couldn't be able to perform her daily activities because of pain mainly and weakness of both the lower limbs.

Patient was taken to the nearby hospital and 

X ray was done which is told to benormal 

MRI was also done 

Patient then complained of anuria for which foleys catherisation was done the she was able to pass urine 

After 10 days she then developed difficulty in swallowing (more to solids ) associated with pain 

No h/o giddiness,LOC, head injury

No history of involuntary movements

PAST HISTORY 

N/k/c/o DM, HTN, thyroid disorders, CVA ,CAD, TB ,EPILEPSY

PERSONAL HISTORY 

Diet: mixed

Appettite: decreased 

Bowel and Bladder: regular

Sleep: adequate

No addictions

1/6/23

4/6/23 to 6/6/23

DAILY ROUTINE: 

She is a Mandala Officer 

She daily wakes at 6 Am and takes bath and fresh up drinks tea at 7am and then she takes her breakfast  (RICE with vegetable curry )at 8am and goes for her mandala office and comes at 1 pm and takes her lunch which consisting of a vegetable curry and rice and after his lich he chit chat with her neighbors and lie down for some time and after that she watch TV and then eats her dinner at 8pm and goes to sleep at 9pm. 

FAMILY HISTORY :- Insignificant

GENERAL EXAMINATION:

Patient is consious, coherent, and cooperative 

moderately built and moderately nourished 

Butterfly like rash present over the cheeks since 6yrs.

Pallor : present

Icterus : absent

Cyanosis : absent 

Clubbing  : present

Lymphadenopathy : absent 

Edema : absent

vitals 

Temperature - Afebrile

Pulse - 83bpm

Blood pressure- 130/80 mmhg

Respiratory rate- 17 cycles per min

Spo2 - 99%

SYSTEMIC EXAMINATION 

CNS  examination: 

HIGHER MENTAL FUNCTIONS:

Oriented to time place and person 

Immediate memory:Intact

Short term memory:Intact

Longterm memory:Intact

No delusions and hallucinations.

Motor system

Power:-

Rt UL - 5/5 

Lt UL-5/5

Rt LL - 2/5  

Lt LL-2/5

Tone:-

Rt UL - normal

Lt LL- normal

Rt LL- normal

Lt LL- normal

Reflexes: 

                   Right                    Left

Biceps:      +++                    +++

Triceps:       ++                  ++

Supinator:  +                       +

Knee:           -                       -

Ankle:            -                       -

Plantar:      Flexion.         Flexion

Involuntary movements - absent

Fasciculations - absent

CVS :-

s1s2 heard,no murmurs

RS:-

Bae+,nvbs heard

P/A:-

soft,non tender,no organomegaly

Investigations:-

1/6/23

Chest x-ray(PA view)

X-ray of both hips

ECG

USG Abdomen

Old MRI 

2/6/23

3/6/23

4/6/23

5/6/23

6/6/23

Provisional diagnosis:-

Spondyloarthropathy associated with Chronic Paraparesis with CKD stage V associated with dysphagia.

Treatment:-

4/6/23 

1.TAB.MVT PO/OD

2.STRICT I/O CHARTING

3.SYP.LACTULOSE 15ML/PO/BD

4.TAB SUCROBIND 500MG PO/OD

5.TAB.NADOSIS 500MG PO/OD

6.TAB.SHELCAL CT PO/OD

7.INJ ERYTHROPOIETIN 4000 IU

8.TAB BUNPRO FORTE WEEKLY ONCE PO/OD

 

9.TAB ULTRACET PO/SOS

5/6/23 

1.INJ NORADRENALINE 2AMP IN 46ml NS @ 4 ml/hr to maintain MAP >65 mmHg

2. TAB.NITROFURANTOIN 100MG PO/TID 

3.IV FLUIDS NS@75ml/hr 

4.SYP.LACTULOSE 15ML PO/TID 

 

4.TAB ULTRACET PO/SOS

6/6/23 

1.TAB.SHECAL PO/OD 

4.SYP.LACTULOSE 15ML PO/TID 

 

4.TAB ULTRACET PO/SOS

4.STRICT I/O CHARTING

5.BP/TEMP/PR/RR HOURLY MONITORING