28yr female with upper and lower limb paresis difficulty in walking

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I have 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 diagnosis and treatment plan .

 This is a case of a 28 years old female, resident of West Bengal and farmer by occupation. 

 

The patient presented to the hospital with chief complaints of 

Pain and weakness in the lower back, right upper limb and right lower limb since 8 years. 

 

The patient was apparently asymptomatic 8 years ago. 

8 years ago, the patient was drawing water while bending forward, when she experienced pain due to a muscle pull in her  right lower back which relived on its own in a few minutes.  The pain was was of sudden onset, dragging in character and progressive in nature. The pain spread from her right lower back to her left lower back, then to her right upper limb and her right lower limb. The pain aggravated on movement and relieved on taking medication over the counter. The severity of the pain changed from one joint to another joint at different times. The pain is intermittent , presnet on movement , not present when she is resting . 

At night, the patient experiences more pain than in the morning. While in the morning, the patient experiences joint stiffness.

For the past 3 years, the patient experiences an increase in the severity of the pain, because of which she resorted to doing only light household work and farm work. She also describes a change in her gait, due to the pain. The patient also describes reduced sensations in the sole of her foot since three years, and frequent cramping of her right foot, frequent episodes of tingling in her right lower limb.

3 years ago, the patient was bitten by a snake ad was rushed to the doctor for treatment. She was given an injection(not known ), due to which she developed a rash over her right arm and forearm, the medication was immediately stopped. The patient suggests that her pain has increased after this incident.

1 year ago the patient visited a doctor, who gave her medication for the pain and suggested to visit a neurologist. The patient consumed the medicines for 1 year, which led to the relief of the pain. On discontinuing the medication the pain increased.

On the left side, the patient suggests that there is tenderness in her joints.  

The patient also complains of weakness in her right upper limb,  right lower limb and lower back.

The weakness was insidious in onset (began 8 years ago with the pain ) , and progressive in nature (first in the right lower back, then progressed to the right upper and lower limb).

The patient describes an inability to climb stairs, inability to bring food to the mouth from the plate without supporting her right elbow, and difficulty in combing her hair with help of the right hand. (Proximal lower limb and proximal upper limb involvement on the right side).

She also describes difficulty in rolling over the bed, the patient sleeps in one position the entire night. She also has difficulty In raising her neck from the bed while she is lying down, without support. There is presence of flaccid muscles  

2 – 3 months ago, the patient experienced giddiness,following intake of a medicine (  name not known - which she is still conuming ) which was sudden in onset, lasted 1-2  minutes, not associated with tinnitus ,aura,or fits. She experienced such episodes every 5 to 6 days.

The patient also complains of headache, at the vertex, sudden in onset, 4-5 episodes per month from the past  2-3 months, that relieve on massage.

 

No history of swelling, skin changes , rash , difficulty in breathing, fasciculations of the muscles, involuntary movements, changing of speech, spilling of food from the mouth, sweating disturbances or palpitations, fever or vomiting.

 

*Past history*

The patient is not a known case of diabetes mellitus, hypertension, tuberculosis, asthma, epilepsy.

The patient describes one occasion fall from her bicycle, which led to pain in her right inguinal and lumbar region. The pain subsided on its own.

 

*Family history*

The patient was born in a non-consanguineous marriage.

The patient’s son experienced one episode of pain and weakness in his lower limbs, which was sudden in onset, did not precede any trauma or fall, non-progressive, which was relived on massage. He was unable to move legs from the bed. Since then he has not had a recurrent episode.

 

*Personal History*

Married

Mixed diet

Adequate quality and quantity of sleep

Normal appetite

Normal bowel and bladder movements

Addictions: consumption of supari since 4 years , 2 - 3 times a dayGeneral Examination -

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

She is conscious, coherent and cooperative.

Built & nourishment-Moderate

No pallor 

No cyanosis

No icterus

No clubbing

No edema

No lymphadenopathy.

Systemic examination:

CVS : 

S1 S2 present

No murmurs

RESPIRATORY SYSTEM;

B/l symmetrical chest

Trachea - Central

B/l air entry present

NVBS heard

ABDOMEN:

Shape of abdomen: scaphoid.

Soft, non tender, no organomegaly present.

No rigidity or guarding.

CNS :

Patient is conscious

Speech-normal 

Signs of meningial irritation

Neck stiffness- negative

Kernings sign-negative

Cranial nerves-intact

Motor system:

Power:

            R.                 L

UL.     4/5.             5/5

LL.      4/5.             5/5

 

Tone:

            R.                  L

UL.      Normal.      Normal

LL.       Incresed    normal

Sensory system: normal

Reflexes:

           Knee. Ankle. Biceps. Triceps supinator

Right    3+.     2+.        -              -            -

Left.     3+.     2+.        -             -           -

Plantar flexion seen.

No cerebellar signs 

Investigations: 

CRP-Negative 

ESR -25mm/1st hour

Diagnosis:

Spondyloarthropathy with Myeloneuropathy

Polymyositis

Course in the hospital:

On Day-1

Patient presented to opd with above complaints and on cns examination it was diagnosed as Myelopathy

On Day-2

To find out the reason for weakness MRI brain and spine was done and it showed 

Few T2/flair hypertense lesions on right side which are oriented perpendicular to ventricles 

Optic nerves,brain stem,spinal cord-Normal

Whole spine screening no abnormalities detected

And then it was diagnosed as spondyloarthritis with Myelopathy 

Polumyositis

On Day -3

As MRI came normal for further assesment of weakness she was sent for nerve conduction studies in nalgonda and it was also normal then she was started with 

Tab.prednisolone 10mg Po/OD

Tab.Naproxene 250mg Po/OD

On Day-4

Same treatment was continued she had no improvement in her weakness

On Day -5

Same treament continued with Tab.prednisolone 10mg Po/OD

Tab.Naproxene 250mg Po/OD

On Day-6

Patient symptoms didnot subsidw even after the treatment and so treament was changed to

Ultracet 1/2tab PO/QID

Tab.Amitriptyline 10mgPo/OD

On Day -7

Same treatment continued  

Ultracet 1/2tab PO/QID

Tab.Amitriptyline 10mgPo/OD

On Day -8

Patient pain was partially relieved  and she is diacharged in hemodynamically stable condition