GENERAL MEDICINE CASE STUDY

A 75 yr old male patient who is resident of nalgonda labourer by occupation came to our hospital for eye surgery 

CHIEF COMPLAINTS:
Loss of vision-left eye
Itching all over th body

HISTORY OF PRESENTING ILLNESS:
 Patient has loss of vision in his left eye since one yr..he has itching all over the body since two months.

HISTORY OF PAST ILLNESS:
Patient was apparently asymptomatic 10 years back.Later,he developed deformities in his lower limbs(resorption and clawing of all the toes).he also lost all his senses(pain ,touch, temperature, vibration).he had hyperflexion of DIPJ nd hyperextension of PIPJ since 2-3 months
.There is burning sensation allover his body.

FAMILY HISTORY:
    No history of DM HTN EPILEPSY asthma cardiovascular disease in his family

PERSONAL HISTORY:
 Mixed diet
Married
Normal bowel and bladder movements
Abnormal sleep patterns
No addictions

GENERAL EXAMINATION:
PHYSICAL EXAMINATION:
No pallor 
No icterus
No cyanosis
No lymphadenopathy
No pedal edema
Wasting of muscles 

VITALS:
Temp: afebrile 
PR:70
BP:130/70
RR:14
GRBS:100 %

SYSTEMIC EXAMINATION:
CVS:
S1 and S2 heard
No thrills 
No murmurs

RESPIRATORY SYSTEM:
No dyspnoea
No wheeze
Trachea is central
Breath sounds are vesicular

ABDOMEN:
No tenderness
No palpable abdominal mass
No spleenomegaly
No hepatosplenomegaly
No bruits
Bowel sounds:NAD

CNS:
Conscious coherent
Cooperative
Speech is normal
Sensory system:
Loss of pain,touch temperature vibration
Loss of sensations over both lower limbs and fore arms
Motor system:
Reflexes lost

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:
    HANSENS DISEASE?

TREATMENT:
TAB TACZINE 5MG ONCE A DAY (FOR ITCHING)

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