GENERAL MEDICINE CASE DISCUSSION
16/12/2022
CASE DISCUSSION:
A 57 yr old male came to OPD who is a farmer came with ,
CHEIF COMPLAINTS:
unable to walk since 3 days
multiple joint pains since 15 days
swelling of bilateral lower limbs since 10 days
HISTORY OF PRESENT ILLNESS :
when he was tring to get up from bed he was unable to do followed by multiple joint pains .no tingling & numbness of limbs
no h/o fever, breathlessness,loose stool, vomitings,decreased urine output
PERSONAL HISTORY :
Appetite: Decreased appetite
Diet:Mixed
Bowel and Bladder habits:regular
Addictions:
He is chronic alcoholic since 10 years ,he drinks daily at around 180ml/day
PAST HISTORY :
There is no history of DM,HTN,TB, EPILEPSY.
No history of blood transfusions.
No history of previous surgeries.
FAMILY HISTORY:
Insignificant
GENERAL EXAMINATION:
PALLOR: ABSENT
ICTERUS:ABSENT
CYANOSIS: ABSENT
CLUBBING OF FINGERS/TOES: ABSENT
LYMPHADENOPATHY: ABSENT
PEDAL EDEMA: ABSENT
SYSTEMIC EXAMINATION :
CVS:
S1,S2 Sounds heard,
No audible murmurs,
Thrills:No.
RESPIRATORY SYSTEM:
Dyspnea is present,
Position of trachea:central,
Normal vesicular breath sounds are heard,
No adventitious sounds
INSPECTION:
INVESTIGATIONS :
12/12/2022
USG (outside) :
ECG :
PROVISIONAL DIAGNOSIS:
paraparesis
TREATMENT:
INJ.LASIX 20mg IV BD
TAB.ALDACTONE 50 mg OD
INJ.MONOCEF 1gm IV BD
INJ.THIAMINE 200 mg IV
INJ.PAN 40 mg IV OD
INJ.NEOMOL 1gm /IV /SOS