A 70 year old male came to the OPD with weakness of all four limbs and oliguria since one week

 The patient's and his attender's consent was obtained, following which detailed history was taken and examination was performed.

HOPI

The patient was apparently asymptomatic one week ago when, the day after his wife's demise, he suddenly developed weakness in all four limbs. His right hand(dominant hand) showed some level of movement. However, he was unable to get out of bed or even brush his own teeth or feed himself.
He was taken to a hospital in Nalgonda and from there, he was referred to this hospital.
He also had reduced urine production around the same time.
He had been caring for his sick wife for the past three months.
Yesterday, he fell while using the washroom and sustained a minor injury to the head. There was some bleeding and he was immediately taken to the OPD and treated.

PAST ILLNESS

15 years ago, he was found to have an abdominal mass which was benign but he refused surgery.
Around the same time (15 years ago)  he underwent hernia surgery.
He underwent cataract surgery for the right eye 6 years ago and for his left eye 3 years ago.
He was recently found to have hypertension (10 days ago).

PERSONAL HISTORY

He was a farmer by occupation and stopped working 6 years ago.
He consumes a mixed diet. Reduced appetite since 3 months. 
He has adequate sleep. 
Normal bowel movements. Oliguria since a week.
No known allergies. 
Patient has a fear of hospitals.
He takes about 360 ml alcohol once in two days.

FAMILY HISTORY

His wife had osteoarthritis which interfered with her daily routine in the last three months, before she passed away.
His son committed suicide 10 years ago.
No other relevant family history.

GENERAL EXAMINATION

Patient was conscious, coherent and cooperative during the examination.
He was well oriented to time, place and person.
Thin build, seems undernourished.
No pallor, icterus, clubbing, cyanosis, bilateral pedal edema or lymphadenopathy.
 










SYSTEMIC EXAMINATION

CNS Examination:
Patient is conscious, coherent and cooperative at the time of examination.
He is well oriented to time, place and person.

SENSORY SYSTEM:

Fine touch, crude touch, pain and temperature sensation and proprioception are intact.

MOTOR SYSTEM:

Bulk: No wasting was observed.

Tone: Normal

Power grading: 
RUL: 4+; LUL: 4+
RLL: 4; LLL: 4

Reflexes:
  1. Biceps: Present
  2. Triceps: Present
  3. Knee jerk: Present
  4. Ankle jerk: Present
  5. Plantar: Present

CRANIAL NERVE EXAMINATION:
  1. Olfactory: sense of smell normal
  2. Optic: intact
  3. Oculomotor: intact
  4. Trochlear: intact
  5. Trigeminal: both sensory and motor components intact
  6. Abducens: intact
  7. Facial: Sensory and motor component intact
  8. Vestibulocochlear: reduced hearing in the left ear
  9. Glossopharyngeal: intact
  10. Vagus: intact
  11. Spinal accessory: intact
  12. Hypoglossal: intact

INVESTIGATIONS















PROVISIONAL DIAGNOSIS

70 year old male came with weakness of all four limbs and oliguria.







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