peripheral Neuropathy with hypothyroidism

This is an online E log book to discuss our patient\"s de -identified health data shared after taking his/her/guardian\"s signed informed consent. Here we discuss our individual patient\"s problems through series of inputs from available global online community of experts with an aim to solve those patient\"s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the log. 

A 45 year old man ,carpenter by occupation presented to the OPD with the chief complaints of Tingling sensation and Numbness in B/L lower limbs extending upto his ankle joint since 15 days

HISTORY OF PRESENT ILLNESS::
Patient was apparently assyptomatic 15 days back then he developed Tingling and numbness in B/L lower limbs extending upto his ankles since 15 days
      He complains of slippage of Footwear, He feels like Walking on cotton
      Alcohol abuse 6months back
      Since 1 week Altered Taste sensation, decreased oral intake
      No Tingling sensation in the upper limbs 
      No Difficulty in getting up sitting posture/climbing stairs
      No Difficulty in button/unbotton on wasting shirt

Past history::
     Pt had B/L pedal edema and jaundice 5 months back which was relieved by medication 
     K/c/o hypothyroidism
     H/o decompesated liver disease
     No H/O Diabetes , Hypertension ,CAD,Asthma,TB 

Family history::
No significant family history

Personal History::
 Married
Diet:mixed
Bowel:Regular
Micturition:Normal
Appetite:lost
Non smoker
Regular Alcoholic

General Examination::
 conscious ,coherent, cooperative
Pulse:80
Bp:110/70
Temp: 99F
Weight:38
Resp.Rate:22
No pallor,cyanosis,Icterus,kylonochyia, Lymphadenopathy,edema

Systemic Examination::
CVS:
S1,S2 + Heard
No murmurs ,Thrills
RS::
BAE+
No Dypnoea,No wheeze
Trachea central in position 
Vesicular breath sounds
Per Abdomen::
Soft
No organomegaly
No palpable mass,Tenderness,free fluid,Bruits
Hernial orifices Normal 

INVESTIGATIONS::
On 17/3/21
On 14/4/21
On 24/6/21

On 26/6/21


Provisional Diagnosis::
Chronic Liver Disease? Peripheral neuropathy with hypothyroidism since 4 months


Treatment::
On 24/6/21 - DAY 1
Inj.OPTINEURON 1 Amp in 100ml NS/PO/BD
TAB.PREGABLIN-M 75mg H/S
TAB.THYRONORM 25mg PO /OD 8 Am
INJ.THIAMINE 1AMP in 100mlNS IV/TID
TAB.PAN 40 mg PO SOS
TAB.UDILIV 300mg PO/BD
TAB.ZOFER 4mg SOS
TAB.DOLO 650 mg PO SOS 
SYP.ASCORIL-D  10 ml PO/SOS

ON 25/6/21-DAY2
Inj.OPTINEURON 1 Amp in 100ml NS/PO/BD
TAB.PREGABLIN-M 75mg H/S
TAB.THYRONORM 25mg PO /OD 8 Am
INJ.THIAMINE 1AMP in 100mlNS IV/TID
TAB.PAN 40 mg PO SOS
TAB.UDILIV 300mg PO/BD
TAB.ZOFER 4mg SOS
TAB.DOLO 650 mg PO SOS 
SYP.ASCORIL-D  10 ml PO/SOS

On 26/6/21-DAY3
Inj.OPTINEURON 1 Amp in 100ml NS/PO/BD
TAB.PREGABLIN-M 75mg H/S
TAB.THYRONORM 25mg PO /OD 8 Am
INJ.THIAMINE 1AMP in 100mlNS IV/TID
TAB.PAN 40 mg PO SOS
TAB.UDILIV 300mg PO/BD
TAB.ZOFER 4mg SOS
TAB.DOLO 650 mg PO SOS 
SYP.ASCORIL-D  10 ml PO/SOS
TAB.BACLOFEN 10mg PO/TID

On 27/6/21 -DAY 4
Inj.OPTINEURON 1 Amp in 100ml NS/PO/BD
TAB.PREGABLIN-M 75mg H/S
TAB.THYRONORM 25mg PO /OD 8 Am
INJ.THIAMINE 1AMP in 100mlNS IV/TID
TAB.PAN 40 mg PO SOS
TAB.UDILIV 300mg PO/BD
TAB.ZOFER 4mg SOS
TAB.DOLO 650 mg PO SOS 
SYP.ASCORIL-D  10 ml PO/SOS
TAB.BACLOFEN 10mg PO/TID

On 28/6/21 -DAY 5

TAB.PREGABLIN-M 75mg H/S
TAB.THYRONORM 25mg PO /OD 8 Am
INJ.THIAMINE 1AMP in 100mlNS IV/TID
TAB.PAN 40 mg PO SOS
TAB.UDILIV 300mg PO/BD
TAB.ZOFER 4mg SOS
TAB.DOLO 650 mg PO SOS 
SYP.ASCORIL-D  10 ml PO/SOS
TAB.BACLOFEN 10mg PO/TID
PROTEIN -X POWDER 2 SCOOPS IN A GLASS OF MILK
TAB. MVT PO OD

 

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