GENERAL MEDICINE BLOG 6
A 67 OLD MALE PATIENT CAME WITH THE RIGHT FOOT DROP AND UNABLE TO WAIK.
Hi I'm Soniya , 3rd sem medical student .This is an online elogbook to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.
CASE SHEET;
CC; A 67 Old male.farmar by occupation residence of Nagarjune Sagar.came with the rt foot drop and unable to walk
HoPI ; pt was apparently asymtomatic 15 years ago then he developed knee joint pain using NSIDS then daily start analgesic unknown medication
10 years ago he presented with pedal edema
3 years ago he slip and fell down (traumatic injury) occur low back but no Lba
After 3 days pt developed Left foot drop and lost sensation over left foot he took some intraarticular inj and he walking all these days
HTN 2 months ago using medication
6 days ago pt developed right foot drop sudden onset
5 days ago he developed with DM
Grade 2 and 3 RPD change noted in both kidney with read cortical cyst
Past history
No history of asthama . Sob .dm .tb
Family history; no
Personal history
Dm since 5 days
Diet mixed
Bowel: Regular
Micturition: Normal
Appetite: Normal
Habits: alcohol intake weekly twice
No smoking
No allergic history
General examination:
Patient is conscious, coherent and cooperative
No pallor
No icterus
No cyanosis
No lymphadenopathy
No clubbing of fingers
pedal edema present
No malnutrition
VITALS:
Temparature 98.6 f
PR 89
BP 140/90
Spo2. 98
Syesmic examination
Cvs :. s1 S2 heard
No murmers
RS : BAE+
Abdomen;
No tenderness
No free fluid
Liver spleen not palpable
Bowel sounds hear
CNS : CONCIOUS
Loss of sensation L4, LT , S1
Fine touch, crude touch, pain lost (L4- S1)
Proprioception - note able to sense toes at all
Vibration:
Medial malleolus -lost
B/L knee-lost
Radial styloid -absent
Olecrenon - absent
REFLEXES: all reflexs are absent
INVESTIGATIONS:
ECG:
ESR:
Peroneal nerve palsy (foot drop)
MEDICATION:
TAB: LASIX 20mg po/bd
Inj: OPTINEURON (amp) 100ml IV od
PHYSIOTHERAPY
MUPIROCIN ointment
