34yr/M with Tingling sensation of all four limbs

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings investigations and come up with diagnosis and treatment plan

C/O

Patient came with c/o Tingling sensation of all four limbs  and generalised weakness since 4 years

HOPI

patient was apparently asymptomatic 4 years ago.then he had H/o electric shock following which he had H/o loss of consious  for 10 to 15 min and had deformities of B/L hands,decreased sensation, Tingling sensation of all four limbs(after which he stopped working and doing farming)

H/o poliomyelities 4 yrs ago and has deformity of both lower limb

No c/o pain abdomen ,fever,loose stools, burning mitcuration, vomiting, cough and cold

PAST HISTORY 

K/C/O HANSENS DISEASE since 4 years and treated with MDT FOR 1 YEAR

K/C/O-poliomyelitis at the age of 4

Not a k/C/O HTN,CAD,TB and asthma

Personal history 

Mixed diet

Normal appatite 

Bowel and bladder movements-regular

No known allergies

Addictions-Beer once for 2 weeks 

                    He used to smoke 5 cigarettes/day and stooped 3 yrs back

GENERAL EXAMINATION 

Patient is conscious coherent and cooperative 

No signs of pallor, icterus, cyanosis, clubbing ,lymphadenopathy and pedal edema

Clinical images 

Vitals-

Temp-febrile 

BP-110/70 mm of Hg

PR-82bpm

RR-18cpm

Spo2-97 on room air

GRBS-90mg/dl

CVS-s1,s2 heard,no murmurs 

Rs-BAE +,NVBS

P/A-SOFT AND NON TENDER

CNS-    

 B/L pupils reacting to light          

TONE-         U/L          L/L

               Rt   N              N

               Lt   N              N

Power             U/L       L/L

                Rt    4/5       4/5

                Lt    4/5        4/5

Reflex            Rt            Lt

                 B     2+           2+

                 T      2+           2+

                 S       +              +

                 K       3+          2+

                 A       -              -

                 P       extensor withdrawal 

Investigations 

DERMATOLOGY REFERRAL done on 22/07/23

O/E-multiple polysized ulcer with granulation tissue noted over lateral side of both lower limbs (lower 1/3rd) and left sole

-3 hypopigmented polysized plagues noted over left knee

-B/L tibia bowing noted

-clawing of B/L hands noted  atrophy of B/L hands (Rt hand-complete claw hand and rt hand _partial claw hand)

-sensation lost over left lower limb , lower 1/3rd of left thigh,rt heal,rt buttocks,rt hand,lateral side of forearm,left extensor aspect of forearm

Impression-TREATED CASE OF HAMSENS DISEASE WITH DEFORMITIES OF BOTH HANDS WITH POLIOMYELITIES OF BOTH LOWER LIMB

ADVISED-SLIT SKIN SMEAR

Treatment-

1.Tab.BACT OINTMENT L/A BD FOR 2 WEEKS

2.LIQUID PARAFFIN L/A BD FOR 4 WEEKS

PROVISIONAL DIAGNOSIS-PERIPHERAL NEUROPATHY SECONDARY TO ELECTRIC SHOCK WITH K/C/O POLIOMYELITIES WITH K/C/O HANSENS DISEASE (treated)no fresh complaints 

Treatment 

1.TAB.PREGABA-M 75 MG PO/HS

2.NEUROBION FORTE PO/BD

3.TAB MVT PO/OD