38 Yr Old Male presented with lower limb weakness and Blurring of Vision

October 12, 2021

M. THARUN KUMAR ROLL NO-87

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Name : M. Tharun Kumar

Roll no : 87

Batch : 2017

CASE :

" 38 year old male who works as a real estate agent came to the opd with chief compliants of giddiness and blurring of vision since 4 days.

History of present Illness:

Patient was apparently asymptomatic 6 years back then he presented with the complaints of intermittent headache and blurring of vision. At 1st time: He complained of headache 6 years back for which he went to government hospital in narketpally and was diagnosed with hypertension. Then later he developed intermittent headache with blurring of vision which subsided on taking antihypertensive medication. The frequency of episodes were 3-4 days/week.

Currently, On friday i.e on 1st october he came to opd with same complaints and given treatment( subsided by sublingual medication).

On sunday i.e 3rd october he came with complaints of acute retention of urine and relieved after foley' s catheterisation. Patient complaints of giddiness since 4 days and blurring of vision. Giddiness was sudden in onset, non rotational. He also complaints of headache associated with blurring of vision and Vomiting which was non bilious and contains food particles.

H/o generalised weakness since 3 days.

PAST HISTORY :

No similar complaints in the past.

He is k/c/o Hypertension since 6 years .He is on T.CLINIDIPINE 10MG AND T.TELMA 40MG.

Patient is not a known case of diabetes mellitus,Tb, Asthma, CAD.

PERSONAL HISTORY :

DIET : mixed

APPETITE : Normal

SLEEP : Adequate

BOWEL AND BLADDER : Decreased Urine output

ADDICTIONS : Smoking : No addiction

Alcohol : consumes around 90ml - 3 times in a week.

ALLERGIES : No food and drug allergies.

FAMILY HISTORY :

No similar complaints in the family.

General Examination:

O/E - pt is conscious,coherent and co operative.

Pallor - no

Icterus - no

Cyanosis - no

Clubbing - no

Lymphadenopathy - no

Edema - no

Vitals: Temp: 103.4 F

PR: 117bpm

BP: 150/90mm hg

RR: 30cpm

Spo2:97% at room air

SYSTEMIC EXAMINATION :

CNS: Higher mental functions:

Intact CRANIAL NERVES

Sensory system- sensitive to pain and touch.

Motor system Right. Left

Power- UL 5/5 5/5

LL 5/5 5/5

Tone- UL Normal Normal

LL Normal Normal

Reflexes- Biceps +++ +++

Triceps +++ +++

Supinator + +

Knee +++ +++

Ankle +++ +++

Plantar Flexion Flexion

Gait- Ataxic

Cerebellar system - intact

CVS:S1S2+ no murmurs heard

RS: BAE+, NVBS

P/A: SOFT, NONTENDER.

Provisional diagnosis:

GIDDINESS UNDER EVALUATION SECONDARY TO ? HYPERTENSION? DEMYELINATING LESION? WITH U/L OPTIC DISC EDEMA WITH PYEREXIA UNDER EVALUATION WITH K/C/O HYPERTENSION.

INVESTIGATIONS:

CUE :