18100006009 CASE PRESENTATIONS

LONG CASE:

Informant: Patient 

A 38 year old male, a resident of chandanapally, nalgonda district came to the hospital with complaints of difficulty in walking since 8 years

Chief complaints: difficulty in walking since 8 years (2014 March)

Feeling weak during walking since 7 years (2015 January)

History of present Illness: The patient had difficulty while walking, while getting up from chair without support, but gets up from chair with support, difficulty in squatting, difficulty in sitting on floor, difficulty in getting up without support from floor.

Initially he had difficulty in going uphill but since 3 years he was complaining of difficulty in walking on level ground also. 

      Uphill: steps are difficult 

      Downhill: comparatively easier steps than uphill

Difficulty in running 

The patient did not have any difficulty in wearing chappals, holding chappals. He did not have any problem in removing chappals. However he complained that it was easier to walk without chappals since there was lesser weight lifting needed. 

After having these symptoms for 8-9 months the patient went to the hospital for checkup and was given medication for which there is no record of with the patient. According to the patient, he was not on regular medication and the medication didn’t improve his symptoms.

Overtime, he had feeling of heaviness of upperlimb while lifting his hand over the head which progressed over time to having difficulty in lifting his arm to shake hands , eat his food and take his brush from the cupboard. He complains that he has to give an increased initial try for him to lift his hand.

After initiating combing, he doesn’t have any difficulty in combing the hair. He feels that it is difficult to move the brush in his mouth.

Difficulty in lifting food to mouth. Not associated with falling of food particles and not associated with falling of food from mouth. No difficulty in chewing food after putting food in the mouth.

Difficulty in bathing with mug. Washes more on the right side with difficulty in washing on the left side. 

Difficulty in getting from bed without support since 1 year. No difficulty in turning to sides on bed.

No difficulty in eating, chewing, closing eyes, swallowing food, whistling, shouting, winking.

Complaints of intermittent spasm of muscles after prolonged sitting. Complaints of muscle cramps. 

No complaint of difficulty in feeling things he touches. No difficulty in feeling chappals sensation. As he walks without chappals he is used to pain while walking and says that his feet are more prone to injuries.

He doesn’t have any difficulty in feeling pain when there is an injury. He doesn’t have ulcerations or abnormal sensations anywhere on the body.

He is able to feel the temperature of the water while bathing. 

The patient doesn’t have any complaints of blurring of vision, difficulty in smell, double vision, vision difficulties, no loss of area of vision, no difficulty in swallowing and tasting, normal facial expressions, no difficulty in hearing sounds of low intensity or high intensity.

No difficulty in turning head, no difficulty in eating or drinking.

No history of loss of consciousness, no irritability to light or sound, no loss of memory, no abnormal visions, sounds, the patient does not use spectacles.

The patient complains the he feels bad that he lost his job as a watchman because of the difficulty in working after onset of difficulty in walking and weakness. But he does not have history of acting out. He feels bad about not earning money but he tells that he got used to the complaints over time.

No history of headaches, nausea, vomiting, involuntary movements.

The patient does not complain of loss of balance or falls but he tells that sometimes while getting up from a chair, he doesn’t have the power to get up and sits back.

No complaints of urgency, hesitancy, increase in frequency during night, difficult in initiating urination, burning during urination.

He had complaints in difficulty in passing stools intermittently for which he takes more water or a tablet and the symptom subsides. He didn’t contact doctor for the complaint as it was intermittent and reduced with more intake of water and bananas.

No history of fever, sleep disturbances, no history of injury to feet.

Birth history: The patient had history of second degree consanguinity and was born at home with the help of dai and apparently without any problem after birth in his words. 

He walked without support at 3 years and started talking in sentences at 7 years of age. He has stuttering while talking but doesn’t have a problem in formation of sentence, language or difficulty in pronunciation of words. He says that he stutters more when there is lack of sleep.

Family history: No history of similar complaints in the family. His mother and father died in an accident  and he is not married due to his stuttering problem at first and weakness later.

Personal history: The patient was a smoker previous for 6 months in 2012 but stopped later. 

He is an occasional alcoholic and drinks one glass of toddy during festivals. No sleep and appetite abnormalities. No bowel and bladder abnormalities.

Past history: The patient had a history of fall from cycle in 2012 after which he had a fracture in the left wrist but did not go to the hospital and took Ayurveda treatment. Now there is a deformity in the left wrist and reduced range of movement with difficulty in using the hand. 

No known history of diabetes, hypertension, bronchial asthma, allergies, tuberculosis, jaundice or prolonged hospital stay.

Drug history: No known usage of drugs for more than 1 week, no history of usage of injections in the hospitals. No known history of any drug allergies. 

Summary: Based on the above history the patient had slowly progressive weakness of the lower limbs more proximal than the distal and overtime it progressed to the upper limbs with more proximal weakness than distal and he developed weakness in the trunk overtime. He doesn’t have spasticity or rigidity in the muscles. He doesn’t have sensory complaints. He complains weakness more in the lower limbs than upper limbs. He has no cerebellar, autonomic system, cranial nerves or higher mental function abnormalities. The patient had history of consanguinity, delayed milestones and history of malunited left wrist fracture.

General physical examination: The patient is conscious, coherent, comfortable, cooperative. No distress or features of pain. The patient doesn’t appear pale. 

There is no icterus, clubbing, cyanosis, pedal edema, generalised lymphadenopathy on examination. 

Weight- 54 kgs

Height- 162 cms 

BMI- 20.57 kg/m2

BP- 110/70mm Hg

Hair, nails, skin and spine- normal

Systemic examination: 

Neurological examination: 

Higher mental functions: The patient is conscious, appears comfortable, language and behaviour appears normal.

Orientation to time place and person normal. Mood and emotional status appears normal.

Memory: immediate, recent and remote memory tested- normal.

Mini mental status examination score- orientation-5/5

Registration-3/3

Attention and calculation- 2/5

Recall- 3/3

Total score- 25/30

No illusions or hallucinations 

Speech: normal verbal output, fluency, repetition, naming, reading, writing.

Appearance- no tics, tremors, myoclonus, involuntary or voluntary movements 

Motor examination: 

Bulk: 

upper limb- right upper limb- 24.5 cms above elbow, 22cms below elbow

Left upper limb- 23.5cms above elbow, 22 cms below elbow

Lower limb- right lower limb- 43 cms above knee, 32 cms below knee

Left lower limb- 43 cms above knee, 32 cms below knee

Tone: hypotonic in right upper limb and lower limb, hypotonic in left upper limb and lower limb.

Power:                                       Right            Left

 Upper limb- distal flexors-       -4/5               -4/5

                      Proximal flexors  3/5                 3/5

 Hand muscles- extensor pollicis longus- 3/5 on both sides, all the others are 4/5 power

Trunk muscles- 3/5 on both sides 

Lowerlimb- hip muscles- iliopsoas- 3/5 on both sides

Adductor femoris- 3/5 on both sides

Hamstring muscles- 3/5 on both sides

Gastrocnemius muscles- -4/5 on both sides

Extensor hallucis longus- -4/5 on both sides

Coordination- normal coordination of movements 

Reflexes: biceps- reduced but present  + on both sides

Supinator- + on both sides

Triceps- + on both sides

Ankle - + on both sides

Plantar- flexor response on both sides

Sensory examination: 

touch- normal on both sides

Temperature- both hot and cold sensation normal on both sides

Vibration- normal on both sides

Joint position- 5/6 times on right side, 6/6 times on left side

Cerebellar examination: 

Hypotonia- present

No rebound phenomenon 

Finger nose test- normal

Finger finger test- normal

Heel shin test- normal

No past pointing, intentional tremor or gait abnormalities.

Gait: normal stride, Normal width, normal turning, The patient is not able to walk on toes.

Cranial nerves: normal smell and vision

Pupillary light reflex- normal, accommodation reflex - normal, normal manual perimetry, normal primary eye movements, normal sensations over the face, normal glabellar tap, corneal reflex, conjunctival reflex and jaw jerk, normal facial expressions, normal taste sensations all over tongue, no deviation of facial muscles or tongue muscles. Normal shrugging, head turn against pressure.

Autonomic system: no bowel bladder abnormalities, no abnormal sweating, no orthostatic hypotension, no postprandial syncopal attacks, no history of falls with loss of consciousness.

Intracranial pressure: no signs of raised intracranial pressure

Skull and spine: normal

Cardiovascular system: 

Inspection: normal on inspection, no visible pulsation, apex beat not visualised. No visible lesions on chest. Equal and symmetrical chest movements with respiration.

Palpation: apex beat felt on the left 5th intercostal space 1cm medial to mid clavicular line. All the findings of inspection are confirmed.

Percussion- all the borders of heart normal on percussion 

Auscultation- s1, s2 heard.

No added sounds, no murmurs heard, normal split heard in s2.

Respiratory system: 

Inspection- normal on inspection, no visible pulsation, apex beat not visualised. No visible lesions on chest. Equal and symmetrical chest movements with respiration.

Palpitation- apex beat felt on the left 5th intercostal space 1cm medial to mid clavicular line. All the findings of inspection are confirmed.

Percussion- no abnormal findings on percussion 

Auscultation- normal vesicular breath sounds heard equally on both sides

Abdominal examination: 

Inspection- normal on inspection, no visible pulsations, no visible lesions on abdomen.

Palpation- no organomegaly

Percussion-

Auscultation- bowel sounds heard at normal frequency 

Ecg- 

Chest X-ray- normal

Serum creatine phoshokinase- 780 IU/ lit

Nerve conduction study- normal 

Elctromyography- reduced amplitude with polyphasic motor response- suggests myopathy

Muscle biopsy report- 

Final diagnosis: 

Based on the above history, examination and findings, the most probable diagnosis is progressing symmetrical proximal muscular dystrophy involving both lower limbs and upper limbs without any known family history or heart involvement so most probably could be beckers or limb girdle muscular dystrophy based on the above mentioned findings.

Differential diagnosis- the other possible diagnosis could be chronic inflammatory demyelination syndrome but it is predominantly sensory and in this case sensory findings are minimal.

Other possible diagnosis could be proximal motor neuropathy or neuronopathy  but there is no history of diabetes or involvement of muscles of neck, swallowing.

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SHORT CASE-1:

Informant: patient’s daughter 

A 58 year old woman presented with the complaints of 

Chief complaints: Shortness of breath with exertion since 1 year and at rest since 15 days

Cough intermittently since 4 months

Swelling of both lower limbs on and off since 2 months

Swelling of right lower limb since 10 days

History of present illness: the patient had complaint of shortness of breath since 1 year which was present with farm work started insidiously, progressing over time, exertional, non seasonal, reached the present state of shortness of breath at rest. Associated with increase during sleeping position and relieved during sitting or standing position.

Complaint of cough with expectoration intermittently, associated with worsening of chest pain, not associated with fever, no diurnal variations. Expectorant- whitish to slightly pinkish in colour, not foul smelling, no plugs, no frank blood.

Complaint of bilateral pedal edema on and off since 2 months, pitting present, extending till ankles, equal on both sides. 

Not associated with chest pain, dizziness, loss of consciousness, abnormal sensations of heart beat.

Not associated with fever, loss of weight.

Associated with increased frequency of urination since 4 months

Past history: No history of similar complaints before 1 year. History of hospitalisation for 3 times in the past one year. Episodes of hospitalisation associated with worsening of shortness of breath, pedal edema and cough. Each time the patient’s attenders gave history of on and off medication intake. 

No history of diabetes, hypertension, bronchial asthma, tuberculosis, jaundice.

No known drug allergies.

Family history: no history of similar complaints in the family. No history of sudden cardiac death in the family.

General physical examination: The patient appears conscious, cooperative, dyspnoea at rest present.

Pulse- rate 86 beats per min 

Rhythm- regular, volume- low volume, equal pulses on both sides and in all peripheral areas, no radio radial delay, no radio femoral delay.

Blood pressure- 120/60mm Hg

Jugular venous pressure- engorged vein, pulsation, the patient has hepatojugular reflex

Respiratory rate - 24 cycles per minute

Spo2 - 96% on room air

Pallor- present, no icterus, cyanosis, clubbing, lymphadenopathy. 

Pedal edema- present, bilateral pitting type, extending till ankles.

Cardiovascular examination: 

Inspection: 

No deformity or bulge in the precordium, apical impulse seen in sixth intercoastal space 1cm lateral to the midclavicular line, no diffuse pulsations over precordium, no superficial engorged veins. No scars or sinuses over the skin.

Pulsations seen on the right parasternal region and in the epigastrium.

No prominent pulsations in  the aortic, suprasternal area, supraclavicular area, no visible carotid pulsation, no visible pulsations on the back.

No kyphosis, scoliosis, drooping of shoulder, winging of scapula.

Palpation: 

Apex beat present in the 6th inter coastal space, left sided, 1cm lateral to the midclavicular line over 2 inter coastal spaces. Parasternal heave present on the right parasternal region, obliterated on pressure. 

Palpable second heart sound in the pulmonary area, not associated with palpable thrill in the pulmonary area.

No other palpable heart sounds, no thrill in carotid pulse, no superficial veins.

Percussion- right border of heart- dull ness on percussion seen till 2.5 cms lateral to the sternal border. Other borders not well localised. 

Auscultation: 

cardiac rate- about 87 beats per minute

Regular in rhythm

Mitral area- soft s1 heard, associated with diastolic murmur mid to late low pitched, no presystolic accentutation, more heard on the left lateral position. No radiation of the murmur heard.

Difficult to appreciate when the patient initially came to the hospital but better audible after initial management.

Pulmonary area- loud p2 heard, no murmur heard, no added sounds

Aortic area- s2 with normal split heard, no murmurs or added sounds heard

Tricuspid area- no murmurs or added sounds heard

Provisional diagnosis- based on the above history and examination the most probable diagnosis is moderate to severe mitral stenosis with frequent acute exacerbations of heart failure.

    

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SHORT CASE-2:

Informant- patient 

Chief complaints: A 54 year old male patient came with Pain in the left side of the chest radiating to the back side since 8 days, difficulty in breathing since two days.

History of present illness: Patient was apparently asymptomatic 8 days back then he developed pain in the left side of chest all over, of stabbing type, which increased on inspiration, radiating to the left upper back.

Pain associated with difficulty in breathing with pain during inspiration, progressing over time, increased with intermittent cough.

Not associated with high grade fever, chills.

No history of shortness of breath before 8 days.

No history of palpitations orthopnoea, PND, headache, burning micturition, vomiting loose stools, cough, fever.

No history of headache, tingling sensation, numbness.

No history of decreased urine output.

History of burning sensation of both feet since 1 year, associated with tingling sensation of both lower limbs extending till ankle, equal on both sides, difficulty in feeling chappals while walking.

Past history: 

The patient has reduced vision in the right eye post trauma and also sustained a leg injury during trauma after which he started using a stick to assist his walking.

He was also operated 10 years back due to a mass in the scrotum (? Inguinal hernia)

There is no history of Hypertension, Diabetes mellitus, epilepsy, bronchial asthma, coronary artery disease.

Family history: no history of similar complaints in the family

Personal history: The patient is a chronic alcoholic and consumes about 180ml of alcohol per day , 4-5 days per week. Not a known smoker. Married and has 2 kids.

General physical examination: On Examination the patient was in sitting position, conscious coherent and cooperative.

Febrile to touch- 99.3F

Pulse- 98 beats per minute, regular, normal volume, no radio radial or radiofemoral delay 

BP 120/100mmHg

No pallor, icterus, clubbing, lymphadenopathy, pedal edema

Spine appears normal

Respiratory examination:

Upper respiratory tract: nose, septum, sinuses, oral cavity and pharyngeal cavity normal.

No mouth breathing.

Lower respiratory tract:

Inspection: The patient is sitting in proper light and was examined. Shape appears to be elliptical. Movements of chest slightly reduced on the left side of chest. Apical impulse not visible. Abdominal type of respiration. About 19 cycles per minute. No visible deviation of trachea. No visible veins or pulsations. No scars, marks or sinuses. Inter coastal fullness present on the left side localised to the lower half. No accessory muscle usage. Normal nipples and muscles on inspection. No audible sounds. No shoulder or spine abnormalities on inspection.

Palpation: Normal surface temperature. No local tenderness. No deviation of trachea. Reduced chest movement on the left side. No spinal or shoulder deformity. Asymmetrical chest expansion seen with reduced movements on the left side. Reduced vocal fremitus in the left infrascapular and left infraaxillary region.

Percussion: Stony dull note on percussion in the left infrascapular region and left infraaxillary region. Normal resonant note in all the other areas.

Auscultation: Bilateral air entry present. Equal sounds on both sides. Normal vesicular breath sounds in right infraclavicular, clavicular, supraclavicular, mammary, scapular, suprascapular, infra scapular and inter scapular regions.

Reduced breath sounds in left infrascapular region and left infra axillary region.

Reduced vocal resonance in the left sided infra axillary and infrascapular regions.

Provisional diagnosis: Based on the above history and examination, the most probable diagnosis is left sided pleural effusion, probably secondary to infection.

Investigations: total leukocyte count- 18000/cumm, hemoglobin- 14Gm/dL, platelets-2.89 lakhs/cumm