48 year male with bilateral foot drop
Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
This E log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome
48 year old male patient from devarakonda,Farmer in cotton field and also works as daily wage labourer ,came with the cheif complaints of
Burning sensation of both lower limbs since
8months
Slippage of slippers since 8months
Hypo pigmented skin lesions on both lower limbs since 8months
HOPI:
Patient was apparently asymptomatic 8months ago when he developed difficulty in holding slippers ,gradually progressive and worsened over last 2months so much so that he stopped wearing slippers,No difficulty in getting up from squatting position,mixing food ,buttoning the shirt,combing hair,no difficult in lifting the head off the pillows,rolling over the bed,no difficulty in breathing or diurnal variation of the weakness
Complaints of burning sensation of both lower limbs gradually progressive since 8 months and has worsened over the last 2months associated with numbness,decreased sleep because of burning sensation,Not associated with tingling or paraesthesias.Patient is able to feel clothes and warm water and cold water during bath.
Complaints of severe pins and needle sensations over outer aspect of leg and patient noticed that when he taps his leg just below the knee on the outer aspect he feels a shock like sensation and pain radiating down on the outer aspect of both legs.No h/o any excess crossed leg sitting posture
No h/o any sensation of walking on cotton wool,no complaints of neck pain ,back pain,band like sensation,
Unsteadiness on closing the eyes+
No h/o Washbasin attacks
No h/o any loss of consciousnesses or altered sensorium,seizures,head injury or trauma to the leg,speech disturbances,no bowel or bladder incontinence,memory disturbances
Sleep disturbances+
No h/o any delusions,hallucinations,emotional disturbances
No h/o any altered no difficulty in sensing smell,vision ,hearing
No tinnitus ,vertigo taste
No difficulty in lifting shoulder,deviation of mouth
Able to roll the tongue and push the food backwards
No h/o any spillage of food while taking it to the mouth or clumsiness of hands
Unsteadiness while walking and closing eyes+
No h/o any palpitations,sweating,able to feel bladders fullness,initiate micturition,feel the passage of urine,able to completely evacuate the bladder
No h/o any bowel disturbances
No h/o Fever ,vomitings,neck pain,trauma,lifting heavy objects on head /back,headache,vomiting,diarrhoea,
Incidentally found to be hepatitis B positive 20days back
Complaints of hypo pigmented skin lesions over both lower limbs since 6months and reduced sensations over the skin lesions.
Complaints of weight loss of 7kgs over the last 4-5 months.
Complaints of transient pain in right upper abdomen and was treated conservatively for gall bladder stones 10days ago.
Past history:
Not a k/c/o DM,HTN,CKD,epilepsy,asthma,TB
No h/o similar complaints in the past
Personal history:
48 Yr old male studied upto 10th class and stopped further studies because of financial issues and started working as a farmer.
Married at the age of 15
Has 1Son 2daughter,all of them married
Alcoholic since 25years and stopped one year back
Non smoker
Mixed diet
Regular bowel and bladder habits
Disturbed sleep patter since 2months
Family history:
No significant family history.
Treatment history :
tenofovir alfenamide since 20days
Pregabalin
Summary:Chronic,Progressive,Distal muscle weakness and sensory involvement probably due to lesion at the level of peripheral nerves at multiple levels ,likely secondary to a infective etiology (Hansens)
General examination:
Patient is conscious,coherent ,cooperative
Thin built
Afebrile to touch
pallor absent
No icterus ,cyanosis,clubbing,lymphadenopathy,pedal edema,no evidence of any neurocutaneous markers
Vitals:
PR:86bpm ,Regular ,normal volume,character,No RR delay,RF delay
BP: 110/80mmhg measured in upper limb in sitting position
Postural drop :absent
RR: 16/min regular ,abdominothoracic
Temp: afebrile
CNS:
Higher mental functions:intact
Cranial nerve examination:
Olfactory-Normal
Optic-
Visual acuity. Cf6 both eyes
Pupils:B/L Normal size,Direct and indirect reflexes +
Accomodation reflex+
Occulomotor,trochlear,abducens
No ptosis,EOM normal
Trigeminal:
Chewing normal
Facial sensations normal
Facial:
Frowning normal
No deviation of mouth
Vestibulochoclear:
Rinnes-AC>BC both ears
Webers-no lateralisation
Glossopharyngeal
Uvula central
Vagoaccesory
Shrugging of shoulders normal
Hypoglossal
Normal tongue movements
MOTOR
Attitude :Sitting on the couch with hands placed on the sides and bilateral foot dangling downwards
Bulk: R. L
UL-Arm. 22cms. 22cms
-Forearm. 21cms. 21cms
LL. -Arm. 33.5cms. 33cms
-Forearm. 24.5cms. 24.5cms
Tone.
Ankle: Hypotonia Hypotonia
Upper limbs and knee normal. Normal
Power:
1.neck flexion. Normal
2.Neck extension Normal
R. L
Upper limb. All: 5/5. 5/5
3.Supraspinatus.
4.Deltoid
5.infraspinatous
6.Rhomboids
7.Serratus anterior
8.Pectoralis major
9.Lattismus dorsi
10.Biceps
11.Brachioradialis
12.Triceps
13.Hand muscles
Trunk muscles :Normal.
Lower limbs:
1.Iliopsoas. 5/5. 5/5
2.adductor femoris 5/5. 5/5
3.Gluteus medius. 5/5. 5/5
4.Gluteus maximus 5/5. 5/5
5.Hamstrings. 5/5. 5/5
6.Quadriceps femoris. 5/5. 5/5
7.Tibialis anterior. 0/5. 0/5
8.Tibialis posterior. 5/5. 5/5
9.peronei 0/5. 0/5
10.FDL. 5/5. 5/5
11.EDL. 0/5. 0/5
12.EHL. 0/5. 0/5.
13.EDB. 0/5. 0/5
Reflexes:
Superficial reflexes:
Corneal+
Conjunctival+
Abdominal
Plantar. Mute. Mute
DTRs:
Biceps. 2+. 2+
Triceps. 2+. 2+
Supinator. 2+. 1+
Knee. 2+. 2+
Ankle. Absent. Absent
EXAMINATION VIDEO:
Gait:High stepping/equine gait
No primitive reflexes
No involuntary movements
SENSORY:
Crude touch
Upper limbs -normal bilaterally
Trunk-normal
Lower limbs-reduced in the lower 1/3rd of anterolateral leg
Reduced over the Dorsum of foot,web space between 1,2nd toes,lateral aspect of foot bilaterally
Pain:
Upper limbs -normal bilaterally
Trunk-normal
Lower limbs-reduced in the lower 2/3 rd of anterolateral leg
Reduced over the Dorsum of foot,web space between 1,2nd toes,lateral aspect of foot bilaterally
Vibration:Reduced distally
Timed Vibration test: R. L
Lower limbs:
Great toe. Absent. Absent
Medial mallelus. Absent. Absent
Knee. Absent. 4.5Sec
Upper limbs:
Ulna. 6.7sec. 7.0sec
Medial epicondyle. 7sec. 7.2sec
Joint position. Absent. Absent
Fine touch :normal in all limbs ,trunk except for reduced fine touch in lower 3rd of anterolateral leg,dorsum of foot
Absent fine touch in the web of 1st and 2nd toe in right lower limb and reduced in left lower limb
Rombergs -Positive (swaying with eyes closed)
Stereognosis: normal
Graphaesthesia:Normal
Tactile localisation:couldn’t be elicited properly
CEREBELLAR SIGNS:
No titubation
Finger nose test,Finger finger test-normal
Heel knee test -normal
No rebound phenomenon
No dysdiadokokinesia
ANS:
Postural hypotension-absent
Resting tachycardia -No
Abnormal sweating -No
MENINGES:
No signs of meningeal irritation
SPINE AND CRANIUM:
normal
No spinal tenderness
PERIPHERAL NERVES:
-Thickened nerves:
Lower limbs :
Bilateral common peroneal palpable
Sural nerve palpable not palpabale
Tibial nerve-not palpable on both sides
Upper limbs:
Ulnar nerve -not Palpable in left cubital tunnel
-No ulcers
-bilateral foot drop +
-No wrist drop
CAROTIDS pulse-Normal ,no bruit
LOCAL EXAMINATION-
Multiple marked hypopigmented and ?hypoanesthetic patches seen over bilateral foot
Asymmetrical
Surface:Dry
surrounding erythema :absent
central healing:No
elevated margin:present
Clarity of margin:good
CVS:Apex 5th ICS,0.5 inch medial to mid clavicular line,Heart sound normal ,no murmur
RS:Tracheal central,Chest elliptical bilaterally symmetrical
Chest movements normal
Normal vesicular breath sounds
P/A :Soft,Non tender
No organomegaly .
Final diagnosis:Chronic peripheral neuropathy with Mononeuritis multiplex pattern involving bilateral superficial peroneal,deep peroneal,Sural nerves in both sensory and motor component with both small and Large fibre involvement
DDs for bilateral foot drop:
DD1: Hansens(Late stage as large fibres are also involved)
In favour of :?Borderline Tuberculoid leprosy,
Few skin lesions with
Early nerve involvement
Hypesthesia and myopathy
Nerve thickening
DD2:Hepatitis B induced peripheral neuropathy? Polyarteritis nodosa with mononeuritis multiplex
DD3:Vasculitis -PAN,Wegeners
DD5:L5 radiculopathy
Justification for Not radiculopathy:
1.No radicular pain
2.No spinal tenderness
3.No clear cut dermatomal distribution of sensory loss
DD5:
Diabetes
Not in favour because:
1.In diabetes Small fibre predominates
2.No history of diabetes
DD6:
Lymes disease:No evidence of any erythema chronicum,Fever,Arthritis
DD7:
Entrapment:Sarcoidosis,Amyloidosis
No other evidence suggestive of these
Further evaluation needed:
1.Slit skin smear from the most hypoanaesthetic macule and skin biopsy
2.Nerve biopsy
3.Nerve conduction study
4.Serology -HIV ,Hepatits B,C
5.HBV viral load,Fibroscan,LFT
6.FBS,PLBS for any impaired glucose tolerance and diabetes
INVESTIGATIONS:
Hb:9.9gm/dl
TLC:7,800
Platelets :2.91
PBS:NC/NC
RBS 80
Urea:32
Creatinine:0.7
Na:141
K:4.1
Cl:102
Total bilirubin 0.37
Direct bilirubin 0.19
AST 16
ALT. 19
ALP. 162
Total protein 5.3
Albumin 3.1
A/G:1.45
CUE:WNL
HBsAG +
HCV-
HIV -
USG abdomen:Norma size and echotexture of liver,cholelithiasis +
ECG:
Nerve conduction study done 8 months ago:Showing reduced CMAP s in bilateral common Peroneal nerve and reduced SNAP in left sural nerve
Comments
Post a Comment