Case history -3



 6/09/2021

Date of admission:2/9/21

A 27yr old men presented to the opd with the complaint of B/L LL swelling since 3days ,

Fever 5 days back for 2 days ,followed by B/L pedal edema upto ankle ,lightness in calf (B/L).

Followed by difficult in climbing stairs and getting up from squatting position in bathroom and difficulty in walking without support.

 

HISTORY OF PRESENT ILLNESS :

-tingling in B/L hands 

-no h/o weakness in U/L

-no involvement of face /axial muscles 

-no difficulty in turning from side to side on bed .

 

HISTORY OF PAST ILLNESS:

No past history of asthma ,epilepsy ,Tb ,HTN,  DM.


PERSONAL HISTORY :

Normal appetite,the patient is non vegetarian,regular bowel movement,normal micturation ,no known allergies ,addictions-occasionally.

FAMILY HISTORY :

No history of diabetes ,hypertension,heart diseases,stroke ,cancers ,tuberculosis,asthma .


GENERAL EXAMINATION:

The patient is conscious,coherent ,cooperative .

No Palar 

No clubbing 

No cyanosis 

No lymphadenopathy 

No malnutrition 

No icterus 

No dehydration 

Edema -present 


VITALS:

Temp-afebrile 

Pulse rate:95/min 

Bp :120/80 mm/hg 

Grbs:141 mg%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills 

Cardiac sounds:s1&s2 heard 

No cardiac murmurs 


Respiratory system:

No dysponea 

No wheeze 

Position of trachea-central 

 

Abdomen :

Shape of abdomen -scaphoid 

No tenderness 

No palpable mass

Hernial orifice -Normal 

No free fluid 

No bruits 

Liver - not palpable 

Spleen -not palpable 

Bowel sounds -yes 


CNS :

Conscious 

Normal speech 

No neck stiffness 

No kerning’s sign 


INVESTIGATIONS:

31/7/21

Complete blood picture :

Haemoglobin:15.2gm/dl 

Total count :9,200 cells/cumm

Neutrophils:59%

Lymphocytes:28%

Eosinophils:5%

Monocytes:8%

Basophils-0%

Platelet count -3.22lakhs/cu.mm 

Smear -normocytic normochromic 

COMPLETE URINE EXAMINATION:


Serum creatinine:


Serum albumin :

2/9/21:
ECG report :


Serum electrolytes :
Complete blood picture:



Complete urine examination:


3/9/21
 
AntiHCV Antibodies 



HIV 1/2rapid test :



HBsAg:


Treatment:
2/9/21
-Inj.1amp optincuron in 100ml Ns IV/OD
-T.Pregabalin 75mg/PO/H/S

3/9/21
-Inj.Thiamine 1amp in 100ml NS/IV/TID
-Inj.Lasix40mg/IV/RD
-I/o charting 
-Bp/PR/spo2 charting 4th hrly

PROVISIONAL DIAGNOSIS:
Wet beri beri 
GB secondary to viral 
FINAL DIAGNOSIS:wet beri beri secondary to alcohol.





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