18 YR OLD MALE WITH COMPLAINT OF DIFFICULTY IN WALKING.
Case : 18 yr old male with difficulty in walking as chief complaint.
I've been given this case 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.
You can find the entire real patient clinical problem in this link here..
https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1
CHIEF COMPLAINTS :
- Difficulty in walking since 1 month.
- Bilateral lower limb weakness since 1 month.
- Pain in calf muscles of lower limbs since 1 month.
- Fever since 1 week.
- History of difficulty in standing from sitting position.
- History of difficulty in climbing stairs.
- History of difficulty in holding slippers.
- History of wasting and thinning of muscles ( LL > UL ).
On examination there is HYPOTONIA and AREFLEXIA suggestive of LMN LESION.
ANATOMICAL LOCATION - ????
- Anterior horn cell
- Ganglion
- Spinal nerve root
- Plexus
- Peripheral nerves
- Neuromuscular junction
- Muscle
ANTERIOR HORN CELL :
. No asymmetrical involvement.
. No fasciculations.
. No atrophy.
GANGLION :
. No severe sensory ataxia.
. No posterior column involvement.
SPINAL NERVE ROOT :
. No pain along the distribution of nerve.
NEUROMUSCULAR JUNCTION :
. No fluctuating weakness.
. No fatigue.
MUSCLE :
. Creatinine kinase - normal levels.
Hence, the anatomical location is PERIPHERAL NERVES.
ETIOPATHOLOGY :
Peripheral neuropathy may be due to axonal neuropathy or demyelinating neuropathy.
On nerve conduction test, it is suggestive of axonal neuropathy.
As the patient is alcoholic and anemic, there is a possibility of deficiency of vitamins like B1, B3, B6, B12 which is one of the causes of peripheral neuropathy.
PROBABLE DIAGNOSIS :
Paraparesis secondary to peripheral neuropathy. ( Bilateral common peroneal and sural nerve ).
TREATMENT :
- Tab. B complex once daily.
- Physiotherapy.
