A old man of age 70 years presented to the hospital with complaints of generalised weakness and pain the oral cavity since 1 month.


                                         The old man was apparently symptomatic when he complained of generalised weakness since 1 month. He states that the weakness is more in the lower limbs than the upper limbs. He describes the weakness as not being able to get up after sitting down. The man states that he finds it difficult to get up from sitting posture since the past 1-2 months.
He has no complains of slippage of footwear.
no h/o any sensory loss in the foot,
no h/o any weakness in the upper limbs,
no h/o any difficulty in buttoning the shirt or combing hair.
No h/o any sensory loss in the upper limb.

                                          The old man also complains f pain in the oral cavity below the tongue since 10 days. Also complains of burning sensation in the epigastric region since 10 days which aggravates on having food.
                                           The old man was a cleaner in the Government services for many years. After retiring from his service he used to be at home most of the time. He used to live with his joint family of 4 brothers. He states that his wife and children had been murdered after which he was disowned by his brothers. He used to live on the streets when a Ashram gave him shelter. He has been with the ashram since then.



General Examination:

The old man is thinly built and poorly nourished conscious oriented to time place and person. 
Pallor - present
Edema -present bilaterally
no signs of 
icterus
cyanosis
clubbing
generalised lymphadenopathy.
Lesions noted on the lower limbs bilaterally.


Central Nervous System

BULK

- Reduced in all the 4 limbs

TONE-                               Right                                    Left


Upper limbs                       Normal                                Normal
Lower limbs                      Normal                                Normal


POWER                       

                                                       Right                                    Left


UPPER LIMB
       Serratus anterior                     3+/5                                       3+/5
       Supraspinatus                         4/5                                          4/5
       Deltoid                                    4+/5                                        4+/5


LOWER LIMB    
        Iliopsoas                                  3+/5                                       3+/5
        Gluteus maximus                    3+/5                                       3+/5
        Gluteus medius 
         and minimus                          3/5                                          3/5
         
          Quadriceps                             4-/5                                        4-/5
          Hamstrings                            4+/5                                       4+/5
Extensor hallucis longus                  4/5                                         4/5



`CARDIOVASCULAR  SYSTEM

S1S2    Heard

RESPIRATORY SYSTEM

Decreased breath sounds heard in the Right infra axillary area.
Bilateral Air entry Present





CBP
hemoglobin-9 gm%
Total count- 8600
Neutrophils- 70
Lymphocytes- 20
Eosinophils- 04%
Monocyte-06%
Platelets- 3.8 lakhs

CUE
Albumin - Nil
Sugar- nil
Paus cells 2-3
Epithelial cells 2-3

LIVER FUNCTION TEST
Total bilirubin -0.48
Direct bilirubin- 0.30

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