CLINICAL CASE DISCUSSION OF PARAPARESIS

CLINICAL CASE DISCUSSION OF PARAPARESIS

Good evening, Iam Sameera of 8th semester I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop comprehensive leraning and understanding skills of the case including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

You can find the entire real patient clinical problem in this link here..

https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1

ANALYSIS OF THE PROBLEM:

 CHIEF COMPLAINTS:

1) difficulty in walking since 1 month

2) bilateral lower limb weakness since 1month

3)pain in lower limb calf muscles since 1 month

4)fever since 1 week

NOTE: As the patient presented with acute onset paraparesis  we need to rule out all  the causes. 

So the differential diagnosis  for acute onset paraparesis :

1. Extramedullary lesions :- 

     a) spinal trauma

     b) pathological fractures

     c) epidural abscess

     d) Dural AVM 

     

2. Intramedullary lesions:- 

     a)demylinating :-  multiple sclerosis,

                                    acute disemminated encephalomyelitis

     b) ischemia:- infarction - trauma , thromboembolism

                             Haemorrhage- vasculitis 

    c) myelitis :- viral, bacterial , parasitic(schistosomiasis).

Reference: www.kznhealth.gov.za/medicine/presentation 48.pdf

Investigations to be done: blood investigations , structural investigation,CSF examination

1-PROBABLE ANATOMICAL LOCATION OF THE PROBLEM:!

We observed that there is hypotonia,hyporeflexia,flaccid paralysis which are characteristic features of LMN LESION(LOWER MOTOR NEURON)

Deep tendon reflexes 

                     Right.             Left

Biceps.          P.                     ---

Triceps.         ---.                   ---

Supinator.     ---                    ---

Knee              ---                    ---

Ankle.            ---                    ---

 Tone:               ul.            normal.         Normal

                         LL.         hypotonia.      hypotonia

Power :almost all the muscles in the leg are showing 3/5 power indicating FLACCID PARALYSIS

SPECIFIC ANATOMIC LOCATION:

Specific anatomical location should be studied to know whether the disease is from either 1)neurogenic

 2)myogenic or

 3) neuromuscular junction

if suspectingMYOGENIC cause then creatine kinase and muscle biopsy should be done.

CREATININE KINASE- 92 IU/L     which is normal so muscle related cause is ruled out.

2)If suspecting Neuromuscular junction cause then electromyography should be done which is also normal in this case so it is ruled out.

3)if suspecting neurogenic cause then..

Nerve conduction studies should be done.

The study shows 

Bilateral common peroneal and sural nerve axonal neuropathy(peripheral neuropathy)Investigations:

NERVE CONDUCTION STUDIES:

2-PHYSIOLOGICAL FUNCTIONAL DISABILTY

     as there is axonal degeneration of neurons there will be functional disability of these nerves resulting in 

       -progressive weakness or clumsiness

       -difficulty in walking

        -absence of reflexes or diminished

3-ETIOPATHOLOGY

FROM the history of the patient he is  alcoholic and ANEMIC. Due to alcohol consumption there can be  deficiency of vitamins like b1,b3,b6 which is one of the cause of peripheral neuropathy.

Calf pain is most common in ALCOHOLIC NEUROPATHY. Due to this there will be metabolic disturbances where there is accumulation of fructose and sorbitol in Schwann cell causing axonal degradation.

https://www.slideshare.net/mobile/meducationdotnet/peripheral-neuropathy-57320857link

Other viral etiology are ruled out using investigation.

4OTHER PRBLEMS FACED

Pain and fever 

       The cause of pain may be due to inflammation of these nerves and fever may be due to any infection which is not ruled out. CSF examination is necessary to rule out the causes of myelitis and other possible causes.

5.TREATMENT PLAN

a)PHARMACOLOGICAL

1-Tablet paracetamol 650 mg thrice daily for fever

2-injection neomol 100ml IV infusion if fever greater than 101° f

3-Tablet .bcomplex once daily for peripheral neuropathy

4-permethrin 5% lotion for scabies \

b)NON PHARMACOLOGICAL

Physiotherapy (muscle strengthening exercises to improve muscle power)

proper lifestyle

avoid alchohol consumption and maintain proper diet.

Thank you.

References: Dr. Hiteesh s presentation  and blog .