Hello everyone, I am an intern in medicine and I am logging cases those I have seen.so that I can share my ideas and can have others thoughts which help in diagnosing or treating patients.
Here is the case of a young boy who came to medicine opd:
CASE:
12/05/2020:
A 18yr old male presented with complaints of difficulty in walking since 1 month
bilateral lower limbs weakness since 1 month
pain in the lower limbs calf muscles since 1 month.
Patient was apparently asymptomatic 1 month back then he gradually developed weakness in both lower limbs which initially felt from getting down from a tractor 1 month back and then he walked with support (walls) which is progressive in nature.
H/o pain in the calf muscles while walking/calf tender positive.
H/o difficulty in standing from sitting position.
H/o difficulty in climbing stairs
H/o difficulty in holding chappals
H/o wasting and thinning of muscles (LL>UL)
No h/o difficulty in getting up from lying down.
no h/o difficulty in holding pen/buttoning/unbuttoning
no h/o difficulty in breathing
no h/o difficulty in lifting the head off the pillow
no h/o difficulty to roll over the bed
no h/o involuntary muscles
no h/o fasciculations/muscle twitchings
h/o slippage of chappal while walking without knowledge
no h/o sensory deficit in feeling clothes
no h/o sensory deficit for hot/cold
no h/o tingling and numbness in UL & LL
no h/o band like sensation
no h/o low backache
no h/o trauma
no h/o giddiness while washing face
no h/o cotton wool sensation
no h/o urgency/hesitancy/increased frequency of urine
no h/o urinary incontinence
h/o fever/
No h/o nausea/ vomiting/diarrhea
no h/o seizures
no h/o spine disturbances
no h/o head trauma
no h/o loss of memory
no h/o abnormality in perception of smell
no h/o blurring of vision
no h/o double vision/difficulty in eye movements
no h/o abnormal sensation of face
no h/o difficulty in chewing food
no h/o difficulty in closing eyes
no h/o drooling of saliva
no h/o giddiness/swaying
no h/o difficulty in swallowing
no h/o dysphagia/dysphasia
no h/o tongue deviation
no h/o difficulty in reaching objects
no h/o tremors/tongue fasciculations
no h/o incoordination during drinking water
no h/o fever/neck stiffness
Past history:
no h/o similar complaints in past
not a known case of DM/HTN/EPILEPSY/CVA/CAD
personal history:
mixed diet with normal appetite and normal bowel/bladder movements
h/o alcohol since 2y weekly twice.
No h/o smoking
no significant family history.
General examination:
Moderately built;poorly nourished
afebrile
Pallor present
Icterus negative
No cyanosis,clubbing,lymphademopathy,Edema.
no short neck
no scars;no h/o tropic ulcers
no neurocutaneous markers
Bp 100/60 mmhg
Pr 80 bpm
Cvs s1 s2 hears no murmurs
Rs bae + nvbs hears
P/a soft ,nontender
Cns HMF- patient conscious
oriented to place/time/person
no h/o aphsia/dysarthria
no h/o dysphonia
no h/o memory loss
no h/o emotional lability
MMSE- 30
cranial nerves- intact
MOTOR SYSTEM
Right. Left
Bulk: inspection decreased. decreased
palpation. decreased. decreased
Measurements U/l 28.5cm. 28.5cm
L/L 37 cm 37 cm
Tone: ul. normal. Normal
LL. hypotonia. hypotonia
Power UL. 5/5. 5/5
iliopsoas 3/5. 3/5
adductor femoris 4/5. 4/5
gluteus medius 3/5. 3/5
gluteus maximus 3/5. 3/5
hamstrings 3/5. 3/5
quadriceps femoris 3/5. 3/5
tibialis anterior. 3/5. 3/5
tibialis posterior. 3/5. 3/5
peroneii. 3/5. 3/5
gastronemius. 4/5. 4/5
extensor -
digitorum longus. 3/5. 3/5
flexor digitorum longus 3/5. 3/5
Reflexes.
Superficial reflexes
Right. Left
Corneal. P P
Conjunctival P. P
Abdominal. + +
Plantar mute mute
cremasteric. + +
Deep tendon reflexes
Right. Left
Biceps. P. ---
Triceps. ---. ---
Supinator. --- ---
Knee --- ---
Ankle. --- ---
SENSORY SYSTEM
RIGHT. LEFT
SPINOTHALAMIC
crude touch. N. N
pain. N. N
temperature. N. N
post:
fine touch. N. N
vibration. N. N
position sensor. N. N
cortical
2 point discrimination N. N
tactile localisation. N. N
CEREBELLUM
titubation - absent
ataxia - absent
hypotonia. present present
INVESTIGATIONS
HEMOGRAM :
HB 10.4gm/dl
Platelets 2.56lakhs/cumm
TLC 10400 cells/cumm
lymphocytes 10%
smear -microcytic hypochromic anemia
serum electrolytes
Na+ 143 meq/l
k+. 3.9meq/l
cl-. 95meq/l
13/5/2020
CASE:
S- patient is conscious
O-
Bp-130/90mmhg
Pr-84 bpm,regular
Cvs: s1 s2 present no murmurs
Rs bae+ nvbs heard.
P/a soft, non tender
cns-hmf intact.
rt. lt
tone ul. N. N
ll. decreased. decreased
power ul. 4/5. 4/5
ll. 3/5. 3/5
biceps. --- ---
triceps. --- ---
supinator. --- ---
knee. --- ---
ankle. --- ---
plantar mute. mute
Temperature charting:
Investigations-
CREATININE KINASE- 92 IU/L
THIS IS DONE TO CHECK FOR ANY NEUROMUSCULAR CONDITION BUT IT CAME NORMAL.
PERIPHERAL BLOOD SMEAR-
Normocytic normochromic
It was sent to see any macrocytes or hypersegmented neutrophils to see for any subacute combined degeneration of spinal cord responsible for paraperesis
SEROLOGY:
HIV,HBsAg,HBC all came as negative.
So that we can exclude viral involvement.
CHEST X-RAY-
ECG:
Diagnosis-
Paraparesis under evaluation -LMN lesion, peripheral neuropathy.
Treatment -
1)T.PCM 650mg/ TID
2)INJ.NEOMOL 100ml/ IV INFUSION IF TEMPERATURE >101F
3) TEMPERATURE CHARTING 4th HOURLY AND TEPID SPONGING
I came to know that chest x-ray and ecg are done for the most patients as general investigations to rule out other comorbid conditions and have a baseline ECG and chest x-ray.
14/5/2020
S- patient is conscious
O-
Bp-120/80mmhg
Pr-82bpm,regular
Cvs: s1 s2 present no murmurs
Rs bae+ nvbs heard.
P/a soft, non tender
cns-hmf intact.
rt. lt
tone ul. N. N
ll. decreased. decreased
power ul. 4/5. 4/5
ll. 3/5. 3/5
biceps. --- ---
triceps. --- ---
supinator. --- ---
knee. --- ---
ankle. --- ---
plantat. mute. mute
Temperature charting
On examination it came to know that he is having scabies as the lesions are present in the webspaces and on asking history he told there are same lesions in his group of members and acquired from each other.(contagious)
To my question these lesions are not pruritic! Which gave me thought of is he immunocompromised letting him no feel of itch!
And may be this immunocompromised state is the reason for his paraperesis. But serology turned out negative.
Investigations-
THYROID PROFILE : it was sent in view of weight loss with myopathy with proximal muscle involvement ?thyroid myopathy!
Diagnosis-
1) paraparesis under evaluation -LMN lesion, peripheral neuropathy
2)scabies
Treatment -
1)T.PCM 650mg/ TID
2)INJ.NEOMOL 100ml/ IV INFUSION IF TEMPERATURE >101F
3)PERMETHRIN 5% LOTION OVERNIGHT APPLICATION ALL OVER BODY EXCEPT FACE
Thoughts-
1)Can it be any other condition where it can be progressing otherthan viral and demyelination diseases?
2)Why hypofunction of thyroid is seen in spinal cord injury?
https://pubmed.ncbi.nlm.nih.gov/6619835/
https://pubmed.ncbi.nlm.nih.gov/8591067/
3) If we think case is a spinal cord injury case based on low T3 levels then why there are no upper motor neuron lesion signs.
15/05/2020:
S- patient is conscious
O-
Bp-126/80mmhg
Pr-83bpm,regular
Cvs: s1 s2 present no murmurs
Rs bae+ nvbs heard.
P/a soft, non tender
cns-hmf intact.
rt. lt
tone ul. N. N
ll. decreased. decreased
power ul. 4/5. 4/5
ll. 3/5. 3/5
biceps. --- ---
triceps. --- ---
supinator. --- ---
knee. --- ---
ankle. --- ---
plantat. mute. mute
Investigation:
we planned to do Nerve conduction study so that we can know whether defect is in axon or myelin sheath.
Treatment:
1)T.PCM 650mg SOS
2)B PLEX OD
16/05/2020:
S- patient is conscious
O-
Bp-120/80mmhg
Pr-80bpm,regular
Cvs: s1 s2 present no murmurs
Rs bae+ nvbs heard.
P/a soft, non tender
cns-hmf intact.
rt. lt
tone ul. N. N
ll. decreased. decreased
power ul. 5/5. 5/5
ll. 3/5. 3/5
biceps. --- ---
triceps. --- ---
supinator. --- ---
knee. --- ---
ankle. --- ---
plantat. mute. mute
Investigations:
NERVE CONDUCTION STUDIES:
Diagnosis:
1) Paraparesis secondary to peripheral neuropathy (bilateral common peroneal nerves and sural nerves).
2)scabies
Treatment:
1)T.PCM 650mg SOS
2)T.B COMPLEX OD
17/05/2020:
S- patient is conscious
O-
Bp-130/80mmhg
Pr-76bpm,regular
Cvs: s1 s2 present no murmurs
Rs bae+ nvbs heard.
P/a soft, non tender
cns-hmf intact.
rt. lt
tone ul. N. N
ll. decreased. decreased
power ul. 4+/5. 4+/5
ll. 3/5. 3/5
biceps. --- ---
triceps. --- ---
supinator. --- ---
knee. --- ---
ankle. --- ---
plantat. mute. mute
Diagnosis:
1) Paraparesis secondary to peripheral neuropathy (bilateral common peroneal nerves and sural nerves).
2)scabies
Treatment:
1)T.B COMPLEX OD
2)PERMETHRIN 5% LOTION OVERNIGHT APPLICATION ALL OVER BODY EXCEPT FACE
18/05/2020:
S- patient is conscious
O-
Bp-120/80mmhg
Pr-72bpm,regular
Cvs: s1 s2 present no murmurs
Rs bae+ nvbs heard.
P/a soft, non tender
cns-hmf intact.
rt. lt
tone ul. N. N
ll. decreased. decreased
power ul. 4+/5. 4+/5
ll. 3/5. 3/5
biceps. --- ---
triceps. --- ---
supinator. --- ---
knee. --- ---
ankle. --- ---
plantat. mute. mute
Investigations:
Planned to do Sural Nerve biopsy so that we can know pathology.
Diagnosis:
1) Paraparesis secondary to peripheral neuropathy (bilateral common peroneal nerves and sural nerves).
2)scabies
Treatment:
1)T.B COMPLEX OD
https://avinashrollnumber1.blogspot.com/2020/05/18yr-old-male-with-complaints-of.html
ReplyDeleteSummary of this case!!
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DeleteSir,what is the amount of alcohol he is consuming??Is it significant enough to cause alcoholic neuropathy?
ReplyDelete90ml everytime and what is the first organ to get effected by alcohol and what can we see in his eyes for that?
DeleteI think brain is the first organ to be affected by alcohol intake.Alcohol related brain damage is due to direct toxic effect of alcohol,nutritional deficiencies (wernicke's encephalopathy)and liver damage (hepatic encephalopathy).Alcohol interferes with absorption of vitamins and conversion of thiamine to it's active form.Wernicke's encephalopathy:ophthalmoplegia and nystagmus,ataxia and changes in mental state.
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