Paraparesis

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

You can find the entire real patient clinical problem in this link 
https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1

Complaints:
 - difficulty in walking since 1 month
 - bilateral lower limbs weakness since 1 month
 - pain in the lower limbs calf muscles since 1 month
 - 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)

Examination:
 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
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 - normal
Cerebellum - normal

INVESTIGATIONS:
HEMOGRAM : 
HB            10.4gm/dl
Platelets  2.56lakhs/cumm
TLC            10400 cells/cumm
lymphocytes 10%
smear -microcytic hypochromic anemia
             later normocytic normochromic

My analysis:
 1. Anatomical location of cause of paraparesis:
 - h/o difficulty in standing from sitting position and h/o difficulty in climbing stairs: suggestive of proximal lower limbs weakness
 - h/o difficulty in holding chappals: suggestive of distal muscle weakness (foot drop)
 - hypotonia  and atrophy in both lower limbs suggest that it is LMN type of lesion
 - involvement of anterior horn cell, dorsal root ganglion, spinal nerves can be ruled out as the distribution is symmetrical 
 - creatinine kinase levels are normal; so we can exclude muscular dystrophy
 - in this case, the lesion could be at the level of peripheral nerve
NERVE CONDUCTION STUDIES:

Nerve cnduction study: suggestive of bilateral common peroneal and sural axonal neuropathy

* Etiology:

 - trauma or injury to the knee; fracture of the fibula ( there is no h/o trauma in this case)     

- Infections 

   SEROLOGY:

   HIV,HBsAg,HBC all came as negative.
   So that we can exclude viral involvement.

 - Alcohol :

   h/o alcohol intake twice weekly(90 ml everytime)since 2 years; 

   alcohol abuse may leads to the deficiency of vitamins B1 and B12( which are essential for proper functioning of nervous system)

  vitamin B12 deficiency --> subacute combined degeneration of spinal cord

 it colud be a reason for peripheral neuropathy in this case

 


*Treatment:

  • vitamin supplements to improve nerve health (folate, thiamin,niacin, and vitamins B6, B12and E)
  • pain relievers
  • physical therapy to help with muscle atrophy
  • orthopedic appliances to stabilize extremities
  • safety gear, such as stabilizing foot gear to prevent injuries
  • special stockings for legs to prevent dizziness

         (https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.healthline.com/health/alcoholism/alcoholic-neuropathy&ved=2ahUKEwi15f_R1tnpAhUKwTgGHbeMD4AQFjAAegQIAhAB&usg=AOvVaw2r6R8MW83ohiBVohZtsf9l&cshid=1590776365532)

 



  

 

  

Comments

Post a Comment

Popular posts from this blog

GM CASES

Image
A 28 year old male came with chief complaints of sudden fall followed by weakness of both the lower limbs (paraplegia) and loss of hand grip 10 days back, associated with bowel and bladder incontinence. History of present illness: Patient was apparently asymptomatic 1 month back, following which he developed productive cough, low grade fever for which he underwent sputum studies and tested positive for AFB bacilli and started ATT - HRZE regimen, 2 tab according to weight/PO/OD. He developed generalized weakness and myalgia 15 days back. 10 days back, patient got up from bed and went to open the door and suddenly fell down, with no loss of consciousness and no froathing. Following which his brother got him up and since then Patient developed bowel and bladder incontinence. No sensory impairment. Past history : He is a known case of TB since 1month and on ATT - HRZE Not a known case of DM,HTN, ASTHMA, EPILEPSY, THYROID DISORDERS, STROKE, CAD. Personal history : Diet - mixed Appetite - no...
Read more

GM CASES

Image
Date of Admission: 28-06-2021 A 52-year-old man presented to the OPD with Cheif Complaints of abdominal distension from the past 7 days. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 2 years back, then he had a non healing injury to the right foot which raised a suspicion of Diabetes mellitus. Then they went to neatest medical care and diagnosed with Diabetes mellitus type 2 and was started on Tab. GLIMI M2 OD.  2 years back he complained of Tingling in the upper limbs up to the palms, in the lower limbs up to the knee.   15 Days back patient presented to the casualty with Abdominal Distension NOT associated with pain, No nausea, No Vomiting, No loose stools and was diagnosed with  Alcoholic Liver Disease, AKI secondary to UTI on CKD, secondary to ? Diabetic nephropathy, Hepatic encephalopathy grade 2 From the past 7 Days, He Complains of Abdominal Distension. From the past 5 days, he complains of Constipation and has not passed stools since 5 day...
Read more

Heart failure

Image
I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  You can find the entire real patient clinical problem in this  https://madhur116.blogspot.com/2020/05/on-1452020.html?m=1 Complaints:   * Shortness of breath:     - since 2weeks     - initially NYHA 3 after treatment now grade 2     - h/o paroxysmal nocturnal dyspnea     - generalised weakness from 2weeks     Causes:     - cardiac     - respiratory     - renal     - metabolic     - anemia     - neuromuscular     - drugs          - we can exclude  respiratory causes as there is no h/o cough, phlegm, pleuritic pain    - renal diseases are ass...
Read more