General Medicine Case Study

Divya.B
Roll no:23


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A   58  year old male resident of suryapet came to the OPD with cheif complaints of pain in the right lower limb since 3 months and tingling sensation in the hands since 3 months.
 History of present illnesses:
    He was apparently asymptomatic 3 months back and then he developed pain in the lower limbs which was insidious in onset gradually progressive non radiating type. Pain aggravated on walking and relieved by rest 
 Pain is not associated with fever,chest pain,cough.
No H/o sweating, palpitations, orthoapnea 
No H/o burning micturition, decreased or increased urine output,loose stools,nausea, vomiting.


Past History:
History of trauma 3 months back .
History of Poliomyelitis since childhood.
No history of Diabetes, Hypertension, Asthma, Tuberculosis, Epilepsy.

Personal History:
Diet : mixed
Apettite: normal
Sleep: adequate
Bowel and bladder movements: regular 
Addictions: no addictions.
Family History:
His mother is hypertensive and diabetic.
General Physical examination
Patient is concious, coherent and cooperative and we'll oriented to time and place.
Vitals
 Temp: afebrile 
Bp: 
PR:72/min
RR:

No pallor
No icterus
No cyanosis
No clubbing
No pedal odema
No lymphadenopathy
 Systemic Examination
CVS:S1,S2 heard and no murmurs.
RESPIRATORY SYSTEM:B/L air entry present. Normal vesicular breath sounds heard.
PER ABDOMEN: 
Shape: ovoid
No tenderness
No organomegaly
No palpable abdominal mass
Bowel sounds heard.
CNS:

Sensory Examination
Pain sensation: present.
Touch
Fine touch and crude touch intact.
Pressure sensation present 
Vibration sense present 
Position sense -intact
Proprioception-intact
Rombergs test: negative 
Stereognosis: present 

 Motor system examination 
Bulk: normal(moderately built)
Tone: normal
Power:grade 5
Reflexes: are present.
                            Right.              Left.
Biceps                  2+.                    2+
Triceps                 2+                     2+
Supinator             2+                     2+
Knee jerk.             4+.                   4+    
Superficial 
reflexes
Cerebellar function
Speech -slurred
Gait- abnormal
Tremors present 
Finger nose test- normal
Dysdiadokinesia- normal
Knee heel test-normal
Nystagmus- absent

Provisional Diagnosis:

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