18 year old male with difficulty in walking
18year old male with difficulty in walking
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 a diagnosis and the following is my analysis of this patients
problems in order of priority are
-weakness of b/l lower limbs since 1 month
-bilateral lower limb weakness since 1 month
-pain in lower limb calf muscles since 1 month
-fever since 1 week
reasons
1.difficulty in walking and weakness of lower limbs
-h/o difficulty in standing from sitting position
h/o difficulty in climbing stairs
h/o difficulty in holding chappals
h/o wasting and thinning of muscles mostly lower limbs
probable diagnosis
-it may be related to nerves because from the history there is history of ddifficulty in holding chappals and wasting and thinning of muscles,difficulty in standing from sitting positin ,difficulty in climbing stairs.
1.Anatomical location of the problem
there is hypotonia,hyporeflexia,flaccid paralysis are seen a characteristic of lmn lesion
power -muscles in the leg re showing 3/5
-it indicates flaccid paralysis.
specific anatomical location:
may be -neurogenic
-myogenic
-neuromuscular junction
-it is not myogenic because creatinine kinase levels are normal
-it i snot neuromuscular junction because electromyography is normal
-nerve conduction studies showed bilateral common peroneal and sural nerve axonal neuropathy(peripheral neuropathy)
2.physiological functional disability
-as there is axonal degenration of neurons so there is functional disabilty of these nerves resulting in
-progressive weakness or clumsiness
-difficulty in walking
-absence of reflexes
3.Etiopathology
he is alcoholic .due to this there is deficiency of vitamins like b1,b3 which may be the cause of peripheral neuropathy
due to this there will be metabolic disturbances where there is accumulation of fructose and sorbitol in schwann cell causing axonal degeneration
4.other problems
-pain
-fever
both r due to inflammation of nerves
other examinations
came to know that he is having scabies as the lesions are present in webspaces and there are sam elesions in his group members
5.treatment plan
a)pharmacologicl component
1-T pcm 650mg thrice daily for fever
2-inj neomol 100ml iv infusion if fever greater than 101f
3-T b complex once daily for peripheral neuropathy
4-permethrin 5% lotion for scabies
b)non pharmacological component
-physiotherapy and alcohol avoidance
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 a diagnosis and the following is my analysis of this patients
problems in order of priority are
-weakness of b/l lower limbs since 1 month
-bilateral lower limb weakness since 1 month
-pain in lower limb calf muscles since 1 month
-fever since 1 week
reasons
1.difficulty in walking and weakness of lower limbs
-h/o difficulty in standing from sitting position
h/o difficulty in climbing stairs
h/o difficulty in holding chappals
h/o wasting and thinning of muscles mostly lower limbs
probable diagnosis
-it may be related to nerves because from the history there is history of ddifficulty in holding chappals and wasting and thinning of muscles,difficulty in standing from sitting positin ,difficulty in climbing stairs.
1.Anatomical location of the problem
there is hypotonia,hyporeflexia,flaccid paralysis are seen a characteristic of lmn lesion
power -muscles in the leg re showing 3/5
-it indicates flaccid paralysis.
specific anatomical location:
may be -neurogenic
-myogenic
-neuromuscular junction
-it is not myogenic because creatinine kinase levels are normal
-it i snot neuromuscular junction because electromyography is normal
-nerve conduction studies showed bilateral common peroneal and sural nerve axonal neuropathy(peripheral neuropathy)
2.physiological functional disability
-as there is axonal degenration of neurons so there is functional disabilty of these nerves resulting in
-progressive weakness or clumsiness
-difficulty in walking
-absence of reflexes
3.Etiopathology
he is alcoholic .due to this there is deficiency of vitamins like b1,b3 which may be the cause of peripheral neuropathy
due to this there will be metabolic disturbances where there is accumulation of fructose and sorbitol in schwann cell causing axonal degeneration
4.other problems
-pain
-fever
both r due to inflammation of nerves
other examinations
came to know that he is having scabies as the lesions are present in webspaces and there are sam elesions in his group members
5.treatment plan
a)pharmacologicl component
1-T pcm 650mg thrice daily for fever
2-inj neomol 100ml iv infusion if fever greater than 101f
3-T b complex once daily for peripheral neuropathy
4-permethrin 5% lotion for scabies
b)non pharmacological component
-physiotherapy and alcohol avoidance
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