A 65 YEAR OLD MALE WITH WEAKNESS IN ALL LIMBS

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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.

This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most welcome.

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

CHIEF COMPLAINTS

⬩ Altered gait since 2 year

⬩ Unable to walk since 3 months

⬩ Stiffness of all limbs since 15 days

⬩ decreased appetite since 15 days

⬩ weakness of all limbs since 15 days

⬩ unresponsiveness since 4 days

HISTORY OF PRESENTING ILLNESS

The patient was alright 2 years ago then he started developing generalised weakness, and complained that he felt like he was walking on pins few times. Generalised weakness caused him to stop working as a goldsmith which he has been doing since his youth. He would still do his own activities like bathing, eating, brushing etc. His routine before included him waking up at 5 am and carrying out his daily activities like brushing, bathing and eating his breakfast before going to work. He would work until 4 pm and then resume his other activities till sleep.

Now he would spend the majority of his time watching tv and carrying out his other routine activities except going to work.

1 year ago he started feeling intermittent weakness in his limbs and feeling pins and needles sensation on his feet. The weakness was gradual in onset and progressing and intermittent. He would go out even less now and spent majority of his time on the bed, uninterested to even watch tv. He was being taken to the hospital multiple times but with no proper diagnosis.

6 months ago he started being scared of walking as he was scared he would fall down, and the pricking sensation in the foot increased.

3 months ago he was taken to a hospital on one such episode of weakness, where they took a MRI in Nalgonda which showed:

- Hydrocephalus

- early Parkinson's changes

They advised to relieve the CSF pressure but due to financial reasons they did not go forward with the procedure.

20 days ago he developed typhoid fever which was diagnosed locally after which he deteriorated even more.

15 days ago he developed stiffness of all the limbs and also weakness in all the limbs. His wife massaged his legs with oil with which his symptoms relieved a little.

15 days ago he started eating less ( decreased appetite )

5 days ago he stopped feeding completely.

3 days ago he developed fever not associated with chills and rigours and became unconscious.

PAST HISTORY

Known case of hypertension since 5 years

Known case of diabetes since 3 years - taking glimipiride 2 mg + metformin 500 mg

No H/O epilepsy, asthma, tuberculosis, CAD

TREATMENT HISTORY

- antihypertensives ( drug unknown )

- oral hypoglycemics - glimipiride 2 mg + metformin 500 mg

- NSAIDS frequently

PERSONAL HISTORY

Diet: mixed

Appetite: decreased

Sleep: adequate

Bowel and bladder: normal

No allergies

Chronic alcoholic since he was 20 years of age and stopped 2 years back - he used to take 250 ml everyday

FAMILY HISTORY

No known family history

GENERAL EXAMINATION

The patient is conscious, not coherent, not cooperative, not oriented to time, place and person.

He is poorly built and malnourished.

VITALS

Temperature: afebrile

BP: 110/70 mm Hg

HR: 92 bpm

RR: 22 cpm

SpO2: 96 %

Pallor present

Skin is dry and patient looks dehydrated

Skin pinch test:

Bed sore:

No cyanosis, icterus, clubbing, lymphadenopathy, edema

SYSTEMIC EXAMINATION

CVS: S1, S2 heard, no murmurs

RESP: NVBS, BAE

PER ABDOMEN: soft, non tender

CENTRAL NERVOUS SYSTEM:

Higher mental function: conscious, non coherent, not oriented to time, place and person.

Language - APHASIC

Unable to write or read

GCS ( Glassgow coma scale)

Eye opening: to speech - 3

Verbal response: no response - 1

Motor response: flex to withdraw from pain - 4

Total score: 8

SENSORY SYSTEM: Cannot be examined

MOTOR SYSTEM: Muscle wasting present, no cramping, no involuntary movements.

CRANIAL NERVE EXAMINATION:

CN 1: OLFACTORY NERVE

CN 2: OPTIC NERVE

CN 3: OCULOMOTOR NERVE - Normal

CN 4: TROCHLEAR NERVE - Normal

CN 5: TRIGEMINAL NERVE - Normal

CN 6: ABDUCENS NERVE - Normal

CN 7: FACIAL NERVE - Normal

CN 8: VESTIBULOCOCHLEAR NERVE

CN 9: GLOSSOPHARYNGEAL NERVE - gag reflex present

CN 10: VAGUS NERVE - difficulty in sleep

CN 11: SPINAL ACCESSORY NERVE

CN 12: HYPOGLOSSAL NERVE

TONE: Hypertonicity in flexors and extensors of both upper and lower limbs

All the limbs were in flexed positing.

Lead pipe rigidity seen.

POWER:

3/5 in the upper limbs

Lower limbs power couldnt be elicited

REFLEXES:

SUPERFICIAL:

- Corneal reflex: present

- Conjunctival reflex: present

- Abdominal reflex: present

- Plantar reflex: present

DEEP:

UPPER LIMB:

LOWER LIMB: Cannot be elicited

No meningeal signs

Gait cannot be seen

PROVISIONAL DIAGNOSIS

- Altered sensorium due to hypovolemic hyponatremia

- Parkinson’s disease

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