CASE OF AN 18 YEAR OLD MALE PATIENT WITH UNDIAGNOSED PARAPARESIS ( BY B.MADHUMITHA , ROLL NO.31).

       I ( B. Madhumitha) have been give this case of an 18 year old male patient 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. 

The entire real patient clinical problem can be found in the  link below:

https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html

          Following is my analysis of this patient's problem:

■The problems of the patient in the order of priority are as follows:

1)Difficulty in walking, in standing from sitting position,in climbing stairs,in holding chappals since 1 month, this was progressive in such a way that he could not walk without support. 

2)Bilateral weakness in lower limbs since 1 month, which was first noticed by patient during getting down the tractor 1 month ago, and also h/o wasting and thinning of muscles .

3)Pain in calf muscles during walking since 1 month.  

4)H/o Fever 

 

■Past history:

No h/o similar complaints in the past, no h/o any trauma, Diabetes , hypertension , epilepsy, cardiovascular diseases.

■Personal history:

His diet is mixed with normal appetite, regular bowel and bladder movements.

He is a Non smoker.

He gave a h/o alcohol consumption since 2 years twice a week.

No significant family history. 

■On observing  his examination findings,  I found that,  

•He is poorly nourished

•Pallor is present.

•He was found to have Scabies  (lesions in web spaces)on examining his hand.

• Motor system of lower limbs:-

  °bulk of the muscle is decreased,       °hypotonia in both the lower limbs,   °power is decreased to 3/5 which is     indicative of flaccid paralysis .

•Plantar reflexes absent. 

•Hyporeflexia is seen.

•Hypotonia, hyporeflexia and flaccid paralysis all together these are characteristic of LMN lesion.

■Lab findings:-

• CREATININE KINASE - Normal

•Thyroid profile showed decreased T3 levels.

•Nerve conduction study revealed bilateral common peroneal and sural axonal neuropathy.

■DIFFERENTIAL DIAGNOSIS 

1)Peripheral neuropathy 

 Which may be caused due to injury(no h/o trauma), infection (ruled out), DM( absent), hypothyroidism ( there is only mild decrease in T3 but the entire thyroid profile is not suggestive of hypothyroidism). Therefore , peripheral neuropathy is ruled out.

2.Neuromuscular conditions(like Myasthenia gravis)

Might not be a neuromuscular condition because, his CK is normal.

3.Autoimmune conditions like MS,GBS but his serology studies are normal.

4.Alcholic neuropathy(?? )occurs due to longterm consumption of alcohol, this causes malabsorption of b1 b6 b9 b12, vit E and absorption of folate.

Deficiency of these b vitamins cause nerve damage. 

But he is been an alcoholic since 2 years only, and that too only twice a week, but there is no information provided regarding the amount and type of alcohol consumed , due to this lack of information i could not surely diagnose it as alcoholic neuropathy. (Query)

■References :

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

2.https://www.healthline.com/health/weakness-in-legs.

3.https://www.google.com/search?q=peripheral+neuropathy+due+to+hypothyroidism&oq=peripheral+neuropathy++due+to+hypothyroidism&aqs=chrome..69i57j0l3.21317j0j7&client=ms-android-samsung&sourceid=chrome-mobile&ie=UTF-8.

4.https://www.ncbi.nlm.nih.gov/books/NBK499856/