46 year old with numbness and weekness

46 Year old female came to the OPD with complaints of tingling sensation in both upper limbs and lower limbs since one month
Patient was apparently a symptomatic Seven years ago gives a history of loss of consciousness for two days and was admitted also gives a history of weakness in both upper limb and lower limbHistory of tingling sensation both upper limb and lower limb along with numbnessOf both upper limbs and lower limbs since one monthShe was advised collar neck and she was diagnosed with cervical spondylitis she presented to casualty with Released weakness and numbness in both upper limb and lower limb . On further probing she gives a history of weakness in upper limb and lower limb 20 days bank and was told hypokalaemia patient denies history of fever and trauma no history of vomiting headache she is not a known case of hypertension and diabetes 
Generall examination 
Pt is c/c/c no pallor, icterus, cyanosis,clubbing,kylonechia,lymphadenopathy,edema
Vitals 
Bp- 120/80 mmhg 

Pr-74 bpm
Rr- 18 cpm
Spo2- 99%
Systemic examination-
Per abdomen - soft non tender bowel sounds heard
Cvs-s1,s2 heard,no murmurs 
Rs- nvbs, BAE+

Cns -Gcs 15/15 
No abnormality detected
Diagnosis Cervical spondylitis 

Treatment:

Inj. Optineuron 1 amp in 100 ml ns @ 75 mg /hr 
Tab. Pregablin 75 mg po/hs 
Tab. Mvt po/oD 
Tab. Ultracet po/bd 
Physiotherapy for neck 
Inj. Tramadol im stat


















Comments

Popular posts from this blog

C/o alternated sensorium since 2 days pedal edema since 20 days

20 year old female with involuntary movements of both upperlimb and lower limb, ?GTCS

55 years old female c/o pain in left shoulder and upper abdomen