18 year young boy
G. Saahithya Reddy
Roll no -141
Medical case:
Chief complaints :
Bilateral lower limb weakness since 1 month
Difficulty in walking since 1 month
Bilateral calf muscle pain since 1 month
History of present illness:
The patient was apparently asymptomatic a month ago after which he had developed bilateral lower limb weakness which was gradually progressive. He noticed the symptom initially while getting down the tractor. He used walking aids.
H/O calf muscle pain while walking and it's tenderness.
H/O difficulty standing from sitting
H/O difficulty in holding the chappals
H/O thinning of muscles (LL > UL)
H/O difficulty in climbing stairs.
This is the positive history for more details please refer to the link given below
https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1
Past history:
He's not a known case of hypertension, diabetes mellitus, thyroid, epilepsy
Personal history :
Diet: mixed
Appetite : normal
Sleep: adequate
Bowel and bladder movements :regular
Addictions: alcoholic since 2 years drinks weekly twice.
General examination:
The patient is conscious, coherent, cooperative, moderately built moderately nourished comfortably sitting on the chair.
Presence of anemia, no uterus, clubbing, cyanosis, lymphadenopathy
Vitals:
Pulse-80 b/min
BP- 100/60 mmHg
Systemic examination
Cvs- S1,S2 sounds are heard
No added sounds or murmurs
Respiratory -bilateral Air entry
Normal vehicular breath sounds heard
GIT-per abdomen soft and non tender
CNS-
Patient is oriented to time, place, person
On observation - no aphasia, dysarthria, dysphonia, no H/O memory loss.
Mini mental status examination score -30
Cranial nerves -intact
Motor system:
Bulk - right. Left
Decreased. Decreased
( on both inspection and palpation)
Measurements ul - 28.5. 28.5
Ll -37. 37
Tone. Ul-normal. Normal
Ll - hypotonia. Hypotonia
Power.
2. neuromuscular junction include involvement of face (ptosis diplopia dysphagia)along with the weakness and in this patient nmj disorder can be ruled out.
3.now we must differentiate between peripheral neuropathy or myopathy.If theres muscle involvement serum creatine kinase is increased and reflexes are intact but in this patient there is loss of reflexes so it might probably be peripheral neuropathy .
to confirm the diagnosis-
nerve conduction studies is done.THE result of ncs can be seen in the above mentioned link.the result states that the patient has :bilateral common peroneal and sural axonal neuropathy.
QUESTIONS:
.2.what is the etipathogenesis of the weakness in this patient?
Since he's an alcoholic since 2 years he could have several vitamin deficiencies like thiamine,folate , B6 , VITAMIN A. Calf pain is common feature of ALCOHOL NEUROPATHY.
3. What are the investigations required?
complete blood count
LFT and RFT
Fasting blood glucose
Nerve biopsy (though not commonly done nowadays)
3. What is the treatment recommended?
Vitamin supplementation
physical therapy
pain killers
Reference
https://pubmed.ncbi.nlm.nih.gov/10804876/
harrison book of medicine
https://www.healthline.com/health/alcohol-related-neurologic-disease#outlook
https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1( hitesh sir blog)
Roll no -141
Medical case:
Chief complaints :
Bilateral lower limb weakness since 1 month
Difficulty in walking since 1 month
Bilateral calf muscle pain since 1 month
History of present illness:
The patient was apparently asymptomatic a month ago after which he had developed bilateral lower limb weakness which was gradually progressive. He noticed the symptom initially while getting down the tractor. He used walking aids.
H/O calf muscle pain while walking and it's tenderness.
H/O difficulty standing from sitting
H/O difficulty in holding the chappals
H/O thinning of muscles (LL > UL)
H/O difficulty in climbing stairs.
This is the positive history for more details please refer to the link given below
https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1
Past history:
He's not a known case of hypertension, diabetes mellitus, thyroid, epilepsy
Personal history :
Diet: mixed
Appetite : normal
Sleep: adequate
Bowel and bladder movements :regular
Addictions: alcoholic since 2 years drinks weekly twice.
General examination:
The patient is conscious, coherent, cooperative, moderately built moderately nourished comfortably sitting on the chair.
Presence of anemia, no uterus, clubbing, cyanosis, lymphadenopathy
Vitals:
Pulse-80 b/min
BP- 100/60 mmHg
Systemic examination
Cvs- S1,S2 sounds are heard
No added sounds or murmurs
Respiratory -bilateral Air entry
Normal vehicular breath sounds heard
GIT-per abdomen soft and non tender
CNS-
Patient is oriented to time, place, person
On observation - no aphasia, dysarthria, dysphonia, no H/O memory loss.
Mini mental status examination score -30
Cranial nerves -intact
Motor system:
Bulk - right. Left
Decreased. Decreased
( on both inspection and palpation)
Measurements ul - 28.5. 28.5
Ll -37. 37
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 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 -
1.Superficial reflexes -normal
Except for the plantar reflex
2.Deep tendon reflexes
Biceps. P. ---
Triceps. ---. ---
Supinator. --- ---
Knee --- ---
Ankle. --- ---
Sensory system -normal
Cerebellum - hypotonia is present.
According to me the priority of events of the patient include :
1. Weakness in both lower limbs
2..difficulty to walk
3. Calf muscle pain
Clinical data analysis :
1. WEAKNESS :
Weakness in this patient is sudden in onset and gradually progressing
The lesion could be :
1. Non - neurological
2. Cortex
3. Brainstem
4. Spinal cord
5. Peripheral nerve involvement
6. Muscle
Non-neurologic condition can be ruled out because he doesn't have any shock related symptoms , electrolyte imbalance, hypoglycemia. ,no trauma, no claudications
CORTEX
Since there's no abnormality in mental status, no visual field abnormalities, sensory system is normal. No seizures. So cortical lesion can be ruled out.
BRAINSTEM
Isolated cranial abnormalities are not present. No sensory involvement. So brainstem lesion can be ruled out.
SPINAL CORD
There's no back pain, no sphincter dysfunction, no sensory abnormalities, only lower motor neuron findings present, upper motor neuron lesion findings are absent.
Lower motor neuron lesion :
The examination findings of the patient like absent reflexes, hypotonia ,wasting of muscles are suggestive of lower motor neuron lesion.
Where is the exact location in the lower motor neuron???
TO know that answer we must have the following questions in mind-
- Symmetrical /asymmetrical involvement
- proximal /distal involvement
- is it sensory /motor
- reflexes absent /present
2. neuromuscular junction include involvement of face (ptosis diplopia dysphagia)along with the weakness and in this patient nmj disorder can be ruled out.
3.now we must differentiate between peripheral neuropathy or myopathy.If theres muscle involvement serum creatine kinase is increased and reflexes are intact but in this patient there is loss of reflexes so it might probably be peripheral neuropathy .
to confirm the diagnosis-
nerve conduction studies is done.THE result of ncs can be seen in the above mentioned link.the result states that the patient has :bilateral common peroneal and sural axonal neuropathy.
QUESTIONS:
- Whatis the anatomical location of the disease?
.2.what is the etipathogenesis of the weakness in this patient?
Since he's an alcoholic since 2 years he could have several vitamin deficiencies like thiamine,folate , B6 , VITAMIN A. Calf pain is common feature of ALCOHOL NEUROPATHY.
3. What are the investigations required?
complete blood count
LFT and RFT
Fasting blood glucose
Nerve biopsy (though not commonly done nowadays)
3. What is the treatment recommended?
Vitamin supplementation
physical therapy
pain killers
Reference
https://pubmed.ncbi.nlm.nih.gov/10804876/
harrison book of medicine
https://www.healthline.com/health/alcohol-related-neurologic-disease#outlook
https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1( hitesh sir blog)
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