1801006070 - SHORT CASE
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42 year old male farmer from kistapuram came with chief complaints of
1) Headache since 3 days
2) Dragging pain of limbs since 3 days
History of presenting illness :
Patient was apparently asymptomatic 1 month back . Following pesticide spraying(Monocrotophos)his farm without any protective equipment , he complained of headache next day followed by episode of vomiting . He came to hospital and took some medications and been on medications for 25 days since then .
3 days back his medicines were over . Then he complained of dragging pain in his upper and lower limbs and headache . Headache is mild to moderate , relieves on taking some rest and aggaravated on working . Dragging pain of upper and lower limbs is constant .
Past History :
Not a known case of Diabetes Mellitus , Hypertension , Asthma , Epilepsy , CAD
Daily Routine
He daily wakes up at 6AM and eats at 8:30AM then he go to field and have lunch at 1:00PM and go back to field and return home by 7:00AM ,have dinner and sleep at 9:00PM.
Personal History :
Diet - Mixed
Appetite - Good
Bowel & Bladder - Regular
Sleep - Adequate
No addictions
No significant Family history
No significant treatment history
General Examination:
Patient is conscious , cooperative , well oriented to time , place , person . Moderately built and nourished .
Patient is examined after taking informed consent in a well lit room .
Pallor - present
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
No pedal Edema
VITALS :
Temperature - Afebrile
Pulse rate - 70 bpm
Respiratory rate - 16 cpm
Blood pressure - 120/60 mm Hg
CNS EXAMINATION:
Right handed person
HIGHER MENTAL FUNCTION :
Counsious ,oreinted to time place person
Speech normal
Behaviour normal
Memory intact
Intelligence normal
REFLEXES:
-Corneal present
-Conjunctival present
-Abdominal: present
-Plantar: present
Deep tendon reflexes :
Knee jerk - 2+
Gait :- normal
Kernig’s sign negative
Brudzinski sign negative
Cvs-
s1 s2 heard
no murmurs
apex beat at mid clavicular line in 5 th intercoastal space.
Respiratory system
I: Chest bilaterally symmetrical, all quadrants
moves equally with respiration
P: Trachea central, chest expansion normal
P: Resonant
A: B/l equal air entry
no added sounds
PerAbdominal examination :-
I :normal
P :soft non tender
No organomegaly
Review of Literature :
Provisional diagnosis-
Headache probably secondary to Monocrotophos (pesticide)with generalized body pains .
Investigations
Haemogram
Complete urine examination
RFT,LFT.
Treatment received
1) Inj.1amp Optineuron in 500ml 0.9% NS IV over 30 minutes.
2) Tab . Aceclofenac PO BD
3) Tab . Naproxen 200mg PO BD
4) Tab . Zofer 4mg PO BD
5) Tab . MVT PO OD
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