70 year old male with fever and weakness

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70 year old male with 

1)fever since 15 days

2)generalised weakness and body pains  in bilateral lower limbs since 10  days

HOPI

Pt was apparently asymptomatic 15 days back then had fever which high grade more during night time associated with chills and rigors it is intermittent not associated with cold , cough, vomitings , loose motions, abdominal pain, burning micturition , no h/o rash, hematuria, bleeding from gums

For which he was taken to local rmp and  got treated for the same and diagnosed typhoid fever and reports from outside showing platelets of 85,000

Then he had generalised body weakness and  pains in bilateral lower limbs and lower back ache since 3days. Pt is unable to walk or stand without support since 3 days

DAILY ROUTINE

He wakes up at morning 6 does his daily routine and takes rice at 8:00-9:00am goes to work ( farmer)  and takes food at 1:00pm returns home at 5:00 pm and takes dinner at 8:00pm qnd goes to sleep

PAST HISTORY 

not a known case of HTN ,DM ,ASTHMA, EPILEPSY , TB,CAD

FAMILY HISTORY

Not significant

PERSONAL HISTORY 

Diet - mixed

Appetite- decreased 

Bowel and bladder movements- regular

sleep- inadequate 

Addictions- takes beedis and chutta daily 4 to 5 since 30years

consumes alcohol occasionally since 30 years 

GENERAL EXAMINATION
pt is conscious coherent notcooperative well oriented to time place person

pallor-absent
icterus- absent
clubbing- absent
cyanosis- absent
edema - absent
lymphadenopathy- absent

VITALS( at admission)

BP - 130/90mm hg

PR- 76bpm

RR- 26cpm

TEMP- 98.6°F

SYSTEMIC  EXAMINATION

CVS - S1, S2 heard

RS - BAE present

PA - soft , non tender

CNS- 

▪sensory examination,- touch, pain present

▪ No muscle wasting seen

▪TONE-         RT.                         LT

 

UL.           hypertonia                hypertonia

LL.             nrml.                         nrml

▪ POWER.

                         RT.                       LT

•UL  

                                            

 Biceps.            5/5.                   5/5

 Triceps.          5/5.                   5/5

 Opponens pollices

                          5/5                   5/5  

 • LL

Extensors of knee

                       5/5.                     4/5  

  Flexors of knee

                     5/5.                       4/5

Exetnsors of hip

                      5/5.                      5/5

External hallucis longus 

                     5/5.                        5/5

 ▪REFLEXES 

 • Deep tendon reflexes

                                   RT.                      LT     

  Knee jerk.          2+                              0              

  Ankle reflex       2+                         0

                               

  Biceps.               3+                            3+

                                       

  Triceps.             2+                           2+

                                   

   Supinator.          3+                          3+

                                    

• Superficial reflexes

▪Babinskis sign 

Flexor on right side

Extensor on left side

 

•Cranial nerve examination

   normal

• Finger-nose in- coordination- yes

•Knee heal test - unable to perform

 

DIAGNOSIS

VIRAL PYREXIA ? CEREBELLAR ATAXIA

INVESTIGAGIONS

outside investigations

4/09/2022

5/9/2022

TREATMENT

IVF 1 NS, 1 RL , 1DNS@ 75 ml/ hr
2) INJ CEFTRIAXONE 1gm IV BD
3)INJ NEOMOL 1gm IV / SOS( if temp >101°F)
4) INJ ZOFER 4mg sos
5) TAB PCM 650 mg PO TID
6) TAB PAN 40 mg IV SOS
7) INJ OPTINEURON 1amp in 100 ml NS IV OD
8) TAB MVT PO OD
9) TEMP MONITORING 2nd hely
10) BP, PR monitoring 4th hrly
11) GRBS monitoring 6th hrly

 

5/9/0022

 IVF 1 NS, 1 RL , 1DNS@ 75 ml/ hr

2) INJ CEFTRIAXONE 1gm IV BD
3)INJ NEOMOL 1gm IV / SOS( if temp >101°F)
4) INJ ZOFER 4mg sos
5) TAB PCM 650 mg PO TID
6) TAB PAN 40 mg IV SOS
7) INJ OPTINEURON 1amp in 100 ml NS IV OD
8) TAB MVT PO OD

9) TEMP MONITORING 2nd hely
10) BP, PR monitoring 4th hrly
11) GRBS monitoring 6th hrly

6/092022

1)IVF 1 NS, 1 RL , 1DNS@ 75 ml/ hr
2) INJ CEFTRIAXONE 1gm IV BD
3)INJ NEOMOL 1gm IV / SOS( if temp >101°F)
4) INJ ZOFER 4mg sos
5) TAB PCM 650 mg PO TID
6) TAB PAN 40 mg IV SOS
7) INJ OPTINEURON 1amp in 100 ml NS IV OD
8) TAB MVT PO OD
9) TAB HIFENAC PO/ BD
10) TAB NEUROKIND LC HS
11)TEMP MONITORING 2nd hrly
12) BP, PR monitoring 4th hrly
13) GRBS monitoring 6th hrly

7/09/2022

1)TAB ECOSPRIN AV 75/10 PO/OD /HS
2) Tab CEFIXIME 200mg PO/BD
3)TAB PCM 650 mg PO/ SOS
4)TAB PAN 40 mg Po/OD
5) TAB MVT PO/ OD
6)TAB HIFENAC PO/BD
7) TAB NEUROKIND LC H/S