58 year old man
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Chief complaints:
• 58 yr old.male with Weakness of bilateral lower limbs since 5 days
History of present illness :
• Patient was apaprently asymptomatic a week back
• 1 year back, he was diagnosed with HTN and was started on Tab TELMA 40mg + Chlorthalidone 6.25mg
• 2 months back he got diagnosed with Covid and received treatment for 1 week and was in home isolation
• On August 31st 2021 , he had fever for which he visited a local hospital and was diagnosed with dengue fever, he was admitted till September 8th after which he got discharged.
• After getting discharged, he started to experience lower back ache which would be present throughout the day, not radiating.
• On September 12th , he paid a visit to a doctor in Khammam and was given pain killers.
• His LBA increased over the next 3 days.
• On September 15th , he paid a visit to an orthopaedician in khammam and was diagnosed with ankylosing spondylitis and was prescribed oral medications of Indomethacin, Ultracet and Bio D3.
After taking these medications, his pain did not reduce.
• On September 16th , he took Diclofenac injections from a local RMP after which he could get a good night's sleep
• On September 17th , he started to even complain of bilateral knee joint pains along with left shoulder pain.
He took his second dose of injection Diclofenac
• He was able to walk with support, with the help of a stick on 17th
• From 18th of September, he even found it difficult to get up from his bed
He is able to make slight movements of his bilateral lower limbs.
He has no complaints of tingling, numbness, pins and needles like sensation.
• No involvement of bowel and bladder.
• No history of tingling and numbness
History of past illness:
• k/c/o HTN since 1 year and on tab. CTD-T 6.25/40mg ( telma 40mg + Chlorthalidone 6.25 mg)
• No history of DM, asthma, Epilepsy, thyroid
Treatment history:
• Has a treatment history of HTN since 1 yr
• Has no treatment history of DM, asthma, cancer, stroke, hormones, surgery, chemoradiation, Antibiotics, CAD, TB, blood transfusion
Personal history:
• He is a farmer, married and a resident of Nalgonda
• Follows mixed diet
• Has regular bowel habits and normal micturition
• Has no known allergies
• Is alcoholic
Family history:
• Has no family history of DM, HTN, asthma, CAD, stroke, cancer, TB
Vitals:
• PR - 110bpm
• BP - 120/80mmHg
• RR - 17cpm
• SpO2 - 98% on RA
• Temperature - Afebrile
Systemic examination:
A. Central Nervous system
• HMF intact
• Tenderness of bilateral knee joint +
• Tenderness in sternal region +
• Tone - Normal
• Power -
Right Left
UL 5/5 5/5
LL 2/5 2/5
• Reflexes -
B 3+ 3+
T 3+ 3+
S 3+ 3+
K 2+ 2+
A + +
P Flexion Bilaterally
• Sensory -
Fine touch +
Crude touch +
Proprioception +
Vibration +
B. Respiratory system
• Lungs - clear
C. Per Abdomen
• Soft
• Non tender
• Bowel sounds +
• Has central obesity
D. Cardiovascular system
• S1 and S2 heard
Treatment:
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