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A 22 YR OLD MALE

Unit 3 admission 

A 22yr old  male,resident of Palleria village, atmakur mandal case to OPD with 

COMPLAINTS OF:

1.Weakness of Bilateral lower limbs since 1week causing unable to walk
2. Fever 5 days back lasted for 3 days

HOPI :

A 22 yr male intellectually disable confined to running errands at home was brought to OPD 

1.WEAKNESS:
- Sudden in onset, gradually progressive intially in B/L lower limbs and then progressed to upper limbs
- Weakness is more in distal portion of limbs compared to proximal region
- Pt is able to roll on bed
- Get up from bed from supine position 
- Able to perceive the sensation of clothes 
- Slippage of foot absent while wearing slippers 
- No bowel & bladder incontinence 

10 days back patient had attended  a ceremony at relative place & Taken food & drank 1 lit of toddy.after which later in the evening, he developed

2. FEVER :
- Low grade,not associated with chills & rigors
- Developed cold along with fever
- Got tested positive for widal test 5 days back & fever relieved by medications 
- no h/o loose stools
- no h/o pain abdomen 

A Happy go lucky boy who indulged in playful activities in the neighborhood could barely get up from 10 days.As the patient is intellectually disabled to the tune that he cannot correlate his life events,although can answer leading questions 

PAST HISTORY :

- Had H/O of pneumonia at 21 days old
- Had H/O of delayed mile stones
* Walking - 3 yrs
* Talking - 5 yrs with slurred speech 
- His mother gave history of her Second degree consanguineous marriage.And the child was last born after five girls
- Known case of Thyroid since 5 yrs.and no other comorbidities 

PERSONAL HISTORY:

1.Diet - mixed
2.Appetite - decreased 
3.Sleep - decreased 
4.Bowel & Bladder movements decreased 
5.Addictions - Regular Toddy drinker since 15 yrs

FAMILY HISTORY  :
- non significant

GENERAL EXAMINATION:

Patient is conscious,coherent  & cooperative. Moderately built & nourished

1.No pallor
2.No icterus
3.No clubbing,cyanosis
4.No koilonychia
5.No lymphadenopathy 
6.No edema
7.Increased carrying angle present
VITALS :

1.Temperature - afebrile 
2. BP - 100/70mmHg
3. PR - 65bpm
4. RR - 20cpm
5.SPO2 - 89
6.GRBS - 102mg/dl

SYSTEMIC EXAMINATION  :

CNS :

CRANIAL NERVES : Intact

SENSORY SYSTEM: Intact

1.Fine touch : +
2.Crude touch : +
3. Vibration : +

MOTOR SYSTEM :

1.ATTITUDE & POSITION: Normal

2. BULK : Wasting +

3. TONE :
- Upper limb : Normal 
- Lower limb(B/L) : Decreased 

4. POWER :
-                  RT            LT 
UL             4/5           4/5
LL              3/5          3/5

5. REFLEXES: 

- SUPERFICIAL  Rt,Lt

1.Corneal - present
2.Conjunctival - present 
3.Abdominal - present 
 
- DEEP 
                     Rt              Lt
1.Biceps      +               +
2.Triceps     +               +
3.Supinator  -               -
4.Knee         -                -
5.Ankle        -                -
6.Plantar     -                -

PER ABDOMEN:

- No distended abdomen
- abdominal tenderness - absent 
- No engorged veins
- Gaurding & rigidity absent

RESPIRATORY SYSTEM:
BAE+ 
NVBS 

CVS :
 S1S2 HEARD 
no thrills no murmurs

PROVISIONAL DIAGNOSIS:

1. Gullain barre syndrome - ?
A. AIDP : acute inflammatory demyelinating polyneuropathy - ?
B. AMAN : acute motor axonal neuropathy - ?

INVESTIGATIONS 

SEROLOGY : NEGATIVE 

HEMOGRAM 

RBS

CUE

LFT

BLOOD UREA 

SEEUM CREATININE 

SERUM ELECTROLYTES 

PHOSPHOROUS 

SERUM CALCIUM 


ECG


CHEST X RAY


2D ECHO

TREATMENT 

1.TAB BENFOMET PLUS OD
2.INJ OPTINEURIN 1 AMP IN 100 ML NS slow iv/OD
3.MONITOR VITALS 4TH HRLY
4.GRBS 12TH HRLY
5. TEMPERATURE CHARTING 

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