Hello all , I’m an intern of 2015 batch , this is a case history of one of our patients who got admitted . This is to complete my log book as a part of internship duties .
Case History
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
TREATMENT
T.pcm 650mg/tid
Ivf-100ml NS with 1 ampoule optineuron IV/OD
Inj.neomol 100ml/iv if temp>101f
Temp charting 6 th hourly and tepid sponging.
PROCEDURE:
I have seen the muscle biopsy from quadriceps femoris in a case of calf muscle hypertrophy ( suspicion of beckers muscular dystrophy)
NEET TOPIC:
Bells palsy is a LMN lesion of facial nerve complaints are deviation of mouth to opposite side,loss of nasolabial fold on same side,unable to close to the eyes, loss of taste ,
Treatment : prednisolone
Antivirals like acyclovir
Eye drops and eye patch
Physiotherapy
This comment has been removed by the author.
ReplyDelete