30 year old female farmer with weakness of both limbs

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A 30 year old female farmer by occupation  Came to opd with complaints of weakness of bilateral lower limbs  and weakness of bilateral hands since 10 days

HOPI:

Patient was apparently   asymptomatic 15 days back then she had fever high grade and loose stools (4-5 episodes) , continuous associated with generalized body pains and joint pains (knee, ankle ,wrist,small joints) relieved with medication. 

2 days later she had pedal edema ,facial puffiness a/w tingling and numbness of both upper and lower limbs ,no burning micturation ,no SOB .then they went to neurologist for weakness of both lower limb and hands 

ENMG - motor axanopathy

Past history :

NO k/c/o DM , HTN,TB,BA ,EPILEPSY 

No H/O previous surgeries 

 

PERSONAL HISTORY:

She follows a mixed diet. 

Appetite -Normal,

Bladder movements- normal 

Bowel movements- Normal . 

Sleep- Adequate.

FAMILY HISTORY: No significant family history.

DRUG HISTORY: No known drug allegies

General examination : 

patient is conscious ,coherrent, co operative and well oriented to her surroundings.

Built: obese

Nourishment: good

no pallor ,no cyanosis, no icterus, no clubbing, lymphadenopathy. 

Pedal edema: pitting type(mild)

- hypopigmented spots seen on trunk since 20 yrs, farmer by occupation. 

-Right handed individual.

Vitals:. 

Temperature: 98.6 F

Pulse rate: 126 beats / min.(resting tachycardia)

 Respiratory rate: 28cycles / min.

 Bp: 120/70mmgh (sitting position)

        120/70mmgh ( standing position)

Spo2: 99 

1.HIGHER MENTAL FUNCTIONS

a.   Conscious/coherent/cooperative 

b.   Orientation to time, place and person

c.   Speech and language  normal 

d.   Memory –normal 

   MMSE score   29/30

I. Orientation 4/5

II. Registration 3/3

III. Attention and calculation 5/5

IV. Recall 3/3

V. Language 9/9

2.CRANIAL NERVES :

I,II,III,IV,V,VI,VII- no abnormality detected 

VIII- nystagmus present in horizontal gaze

IX,X,XI,XII- no abnormality detected 

3.MOTOR SYSTEM 

I – BULK

a.      Inspection -  b/l normal 

b.     Palpation -  b/l normal

c.      Measurements

Upper limb – 10cm above and below acromion

RT-12cms  lt-30cms

Lower limb- 18cm above and 10cm below 

Acromion tubercle

Rt-30cms  lt-30cms

II – TONE

a.      Upper limbs-  b/l normal

b.     Lower limbs-   hypotonia b/l

III – POWER

a.      Neck muscles - good 

b.     Upper limbs

i)                Shoulder  b/l 5/5

ii)              Elbow  b/l 4/5

iii)             Wrist  b/l 3/5 

iv)       small muscles of hand 4/5 right, 4/5 left

v)        Hand grip  20% b/l

 c.      Lower limbs

i)                Hip b/l 4/5

ii)              Knee b/l 3/5 

iii)             Ankle b/l  1/5 

iv)        Small muscles of foot  b/l  1/5

 

d.     Trunk muscles - getting up with support 

e.      Beevor’s sign- negative 

 

IV – REFLEXES

A.    SUPERFICIAL REFLEXES

1.     Corneal  b/l present

2.     Conjunctival reflex b/l present 

3.     Palatal Reflex present 

4.    Abdominal Reflex    absent 

5.plantar reflex mute b/l 

B.    DEEP TENDON REFLEXES

1.     Pectoralis jerk absent b/l 

2..     Biceps jerk absent b/l 

3.     Triceps jerk absent b/l 

4.   Supinator jerk absent b/l

5.   Finger flexion reflex absent b/l

6.     Knee jerk absent b/l 

7.     Ankle jerk absent b/l 

8.  Clonus  absent

C.      OTHERS

Hoffmans sign - negative

D.GAIT  ataxic 

  

4.SENSORY SYSTEM 

I.spinothalamic

1. Crude touch    b/l normal

2.Pain  b/l normal

3.Temperature  b/l normal

II.posterior column 

1.Fine touch   b/l normal

2.Vibration   b/l normal

3.Position sense    b/l normal

4.Rombergs sign  b/l normal

5.   CEREBELLAR SIGNS

1.      NO Titubation  

2.     Gait ataxia present

3     Nystagmus present 

4.    Hypotonia both lower limbs 

5.  Coordination

a.      Upper Limbs – Finger Nose test normal 

 Finger Finger Nose test normal 

b.    Dysdiadokokinesia normal 

 6.   AUTONOMIC NERVOUS SYSTEM

 NO Postural Hypotension 

Resting tachycardia 124 bpm present 

Abnormal sweating absent 

7.    SIGNS OF MENINGEAL IRRITATION

Neck stiffness absent 

Kernig’s sign absent 

Brudzinski’s sign absent 

8.    EXAMINATION OF THE SPINE AND CRANIUM

SPINE – bony deformities, bruit, gibbus, tenderness - absent 

9.    PERIPHERAL NERVES

NO Thickened nerves 

NO  Trophic ulcers 

EXAMINATION OF OTHER SYSTEMS

CARDIOVASCULAR SYSTEM:  

JVP not raised , Apex normally placed, 

no Palpable P2

, Heart sounds – normal

, No thrills/murmurs

RESPIRATORY SYSTEM: Chest symmetrical, No paradoxical movements, Normal vesicular breath sounds heard,

No abnormal/added sound

ABDOMEN: Abdomen is soft, No organomegaly, No ascites, 

Investigations:

LFT: on 1/4/2022

TB- 0.57

DB- 0.29

AST- 32

ALT- 60

ASP- 146

TP- 7.2

ACB- 4.0

A/G RATIO- 1.28

Ecg:

crp - negative

Esr -70mm / 1st hour

Fasting blood sugar -113mg/dl

CBP on 01/04/22:

CUE:

Renal function tests :

Blood urea - 34 

Serum creatinine-0.8

Serum electrolytes 

Sodium  136 

Potassium 3.8

Chloride 99

Serology : negative done on 03/04/22

Thyroid profile:on 03/04/22

T3 - 0.59

T4- 10.70

Tsh- 4.65

Usg report of abdomen and pelvis:

Hemogram on 2/04/22:

CBP on 03/04/22:

chest xray:on 1/04/22

xray lspine :

Chest x ray on 03/04/22

Provisional diagnosis:

?acute motor axonal Neuropathy 

1.inj OPTINEURON 1amp  in 100ml NS IV OD
2.TAB PREGABALIN 75mg/Hs
3.TAB ZINCOVIT 1 tab PO OD
4.TAB PAN 40MG PO OD
5.TAB DOLO 650 MG PO SOS

6.BP/ PR/TEMP monitoring every 4th hourly

7.physiotherapy of both upper and lower limbs

NEW ADMISSION 

01/04/22

AMC BED 1 

S: no fresh complaints by the patient ,patient symptomatically improved

O: 

O/E pt is c/c/c

No pallor/icterus/cyanosis/clubbing/lymphadenopathy 

Vitals:

Temperature: 98.6°F

BP: 120/100 mmHg

PR: 104 bpm 

CVS: S1 S2 +

RS: BAE+

CNS:

No change in Tone of muscles

 Reflexes: areflexia seen in both the limbs

Hand grip increased from 20 to 40% 

P/A: soft,non tender 

A: no clinical detoariation

??Acute motor Axonal Neuropathy 

P: 

1.inj OPTINEURON 1amp  in 100ml NS IV OD

2 .TAB DOLO 650mg PO SOS

3 .BP/ PR/TEMP monitoring every 4th hourly

4.physiotherapy of both upper and lower limbs

AMC updates 03/04/22

 

30 year old /female 

S:no fresh complaints by the patient ,patient symptomatically improved

O: 

O/E pt is c/c/c

No pallor/icterus/cyanosis/clubbing/lymphadenopathy 

Vitals:

Temperature: 98.6°F

BP: 120/100 mmHg

PR: 110 bpm 

CVS: S1 S2 +

RS: BAE+

CNS:

GCS -15/15

Nytagamus +

Power RT   LT

UL       5/5   5/5

LL        4/5   4/5

 

Tone     

UL        N          N

LL      decreased on both sides 

Hand grip 30% on both sides 

            

P/A: soft,non tender 

New Investigations :

Serology : negative 

Thyroid profile:

T3 - 0.59

T4- 10.70

Tsh- 4.65

A: no clinical detoariation

??Acute motor Axonal Neuropathy 

 

P: 

1.inj OPTINEURON 1amp  in 100ml NS IV OD

2.TAB PREGABALIN 75mg/Hs

3.TAB ZINCOVIT 1 tab PO OD

4.TAB PAN 40MG PO O