50 year old man with chief complaint of generalised weakness
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Date of admission 11-3-22 10:30 am
50 year old man resident of nalgonda farmer by occupation presented to opd with chief complaint of generalised weakness since 1day
HISTORY OF PRESENT ILLNESS
He was asymptomatic 5 year back and later he developed symptom of giddiness and fell to ground and after 10 min he use to get up and walk
This episodes of symptoms were repeated 3 to 5 times for year from past 5 years
On 9th march he developed same symptom but this time he fell to ground and he is not be able to stand ,
after 30 min when his son arrived there to check him, his son supported him to stand up
People who saw him fell to ground reported that he got seizures
which were first time for him , reported by his son
PAST HISTORY
Hypotension since 2 years
diabetes since 3 years
Injury at left ankle during his child hood so his gait was not proper
FAMILY HISTORY
No significance
PERSONAL HISTORY
Mixed diet
Smoking daily 15 beedis
Not alcoholic
Daily routine:-
Daily 4am wake up
Cattle care and working in farm next to his house till 7am
7am hygiene
9am drinking tea and eating rice and curry *
Lunch at 2 pm
Supper at 9pm
He works next to his home as he has farming lands of his own
He use to walk 5 to 10km daily
GENERAL EXAMINATION
No clubbing
No cyanosis
No pallor
No icterus
Percussion of abdomen
No fluid present
No palpable mass
Liver not palpable
Vitals
Temp 98.4
Respiration 18 cycles per min
Bp 160/90
Pulse 76 beats /min
Respiratory system
Bilateral breath sounds are not heard
No wheezing sounds
No crepitations
CVS
S1 and S2 are heard
No apex beat
No jvp seen
No palpitations
CNS
conscious , coperative ,coherent
Reflexes are normal
No speach problems
Gait was abnormal
Oral examination
Fissured tongue
Gingival recission
Caries tooth posteriorly
Pigmented gingiva anterior due to smoking
Gingivitis
Attrition of all teeth
INVESTIGATIONS
Serum electrolytes
Na :-140 (136-145)
K :- 4.1(3.5 - 5.1)
Cl:- 99(98 -107)
Rbs
130 (100-160)
Complete blood picture
Total count *17,400(4000- 10000)
Lymphocytes:- *15 (20- 40)
Ecg
Left eye showing cotton white appearance
Right eye showing cotton white appearance
Clinical images of his lower limbs showing no sign of any inflammation or swellings
Abdomen clinical image showing no sign of any inflammation or swelling
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