A 55Y M with tingling sensation and weakness of Rt upper and lower limbs
1st July 2023
NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.
This is the case of a 55-year-old male, resident of Tirumalagiri, and Farmer by occupation. The following history was taken with the patient in person. The patient was explained about confidentiality and written consent was taken to create the following case report.
This case report aims to record the patient's journey.
CHIEF COMPLAINTS:-
1. Tingling sensation in Rt upper and lower limbs since 29th June
2. Weakness in the Rt upper and lower limbs since 29th June
History of present illness:-
Pt was apparently asymptomatic before 29th of June, afterwhich he then developed weakness of Right upper and lower limbs which is described to be insidious in onset (1st the right leg was affected), gradually progressive in nature. Weakness is associated with tingling sensation. Every one hour this tingling sensation is noticed. This sensation aggrevates during the night. There are no noted relieving factors. The patient faces difficulty in standing and walking by himself. Slipping of chappals present while walking. However there is no tripping of toes. The patient also faces difficulty in taking in food, combing hair and buttoning up his shirt by himself.
The patient is able to feel clothes but wasn't able to differentiate between hot and cold sensation as well as feel the pin and needle sensation. Slurring of speech was present.
Decreased hearing in both the ears since 10 years.
Daily routine
The patient wakes up at 6am. Follows a sedentary lifestyle. Has three meals. Has proper sleep (without any disturbance).
Negative history
No c/o deviation of mouth , loss of consciousness, headache, giddiness, vomitings, Pain
No H/o involuntary passage of urine or stools
No H/o fever , loose stools , sob , pain abdomen.
No h/o visual disturbances, headache, diplopia, ptosis, he is able to appreciate smell, he is able to look towards all sides no h/o sensory loss over the face, no facial deviation.
No noted sensory deficit as the patient was able to feel clothes, feeling hot and cold water while bathing.
No h/o auditory disturbances
No h/o restricted tongue movements
No difficulty in swallowing
No difficulty in speaking
No h/o abnormal sweating
No h/o shooting pain
No h/o headache or vomiting.
No h/o seizures
No h/o Fasciculations/muscle twitchings.
No h/o Involuntary movements like chorea, athetosis, hemiballismus
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History of past illness:-
The patient does not have any history of TB, HTN, DM, Epilepsy and asthma.
No h/o of past illnesses or surgery.
Personal history:-
Water intake:- normal
Appetite:- normal
Diet:- mixed
Bowel movement:- normal
Bladder movement:- normal
Alcohol:- stopped alcohol 8 months back.
Smoking:- stopped smoking 8 months back.
Addiction:- nil
Allergies:- nil
Exercise status:- nil
FAMILY HISTORY:-
- Patient parents were in a consagiunius marraige.
- Patients father has faced the similar symptoms.
PHYSICAL EXAMINATION:-
GENERAL EXAMINATION:-
The examination was conducted at a well lit and well ventilated room. The patient was conscious, cooperative and coherent.
Moderately built
Afebrile
No Palor
No Icterus
No Cyanosis
No Clubbing
No Pedal edema
No Significant lymphadenopathy
CNS EXAMINATION:-
Bulk
rt lf
Arm 23 cm 23cm
Forearm 24cm 24cm
Leg 29cm 29cm
Tone
rt lf
Arm increased normal
Leg increased normal
Power
rt lf
Upper limb 4/5 5/5
Lower limb 4/5 5/5
-Hemiplegic gait
Cerebellar signs
No coordination seen in finger nose test.
No coordination seen in knee heel test.
CLINICAL PICTURES:-
REPORTS:-
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