General medicine e- log book - 5

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Case : A 18 Year old male with Paraparesis

Written by: Shravani Reddy, Roll no:15, 8th semester

I have been given this case

https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1

 to solve in an attempt to understand the  "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.

The problems in order of priority I found are:

  • PARAPARESIS : causing difficulty in walking from 1 month (Date of admission:may 12th 2020)
  • Bilateral lower limb weakness from 1 month
  • PAIN in the lower limbs calf muscles from 1 month
  • Difficulty in standing from sitting position
  • Difficulty in climbing stairs 
  • Difficulty in holding chappals
  • Wasting and thinning of muscles (LL>UL)
  • Fever from 1 week

On examination:(positive findings)

  • Pallor is present(HB : 10.4 gm/dl)
  • Muscle bulk is reduced in both lower limbs(on inspection and palpation)
  • Hypotonia in both lower limbs
  • Babinski sign is negative
  • Deep tendon reflexes are absent
  • Lesions are present in the web spaces indicative of scabies (family history - has scabies as it is a contagious disease)

  • History of alcohol intake from 2 years weekly twice.

Investigations :

  1. Peripheral blood smear shows NORMOCYTIC NORMOCHROMIC ANEMIA
  2. Serology : HIV, HBsAg ,HBC all came as NEGATIVE
  3. Chest X ray - NORMAL
  4. ECG - NORMAL
  5. Thyroid profile - NORMAL
  6. Nerve Conduction Study- to know whether defect is in myelin sheath or in axon.In this patient ,it indicated bilateral common peroneal and sural neuropathy.
  7. Normal CREATININE KINASE LEVEL

From above investigations we can rule out following diseases:

  1. Vitamin B12 deficiency
  2. No viral involvement
  3. Thyroid induced myopathy
  4. No neuromuscular condition(as creatinine kinase level normal)
From above findings.....
i.e.: HYPOTONIA , WASTING , ABSENT DEEP TENDON REFLEXES suggestive of LOWER MOTOR NEURON (LMN) LESION.


ANATOMICAL LOCATION OF ROOT CAUSE:

It could be in  the axons of the peripheral nerves because 
  • Motor functions are affected
  • Difficulty in holding chappals
  • Ankle jerk reflex is absent
  • Nerve conduction study indicated bilateral common peroneal and sural neuropathy.

PROVISIONAL DIAGNOSIS:
  • Paraparesis secondary to peripheral neuropathy( bilateral common peroneal nerve and sural nerve involved).
  • Scabies
TREATMENT:

PHARMACOLOGICAL COMPONENT:
  • Tab.pcm  650 mg thrice daily for fever 
  • Tab.B -COMPLEX once daily for peripheral neuropathy
  • Permethrin 5% lotion overnight application all over the body except face for scabies 
NON PHARMACOLOGICAL COMPONENT:
  • Proper diet recommended
  • Physical therapy to help with the muscle atrophy

References:


Thanks and regards,
Shravani Reddy.










 







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