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Tuesday, June 2, 2020

Medicine Intern Log

Hello everyone, I am a medical intern, and recently started my Medicine posting. This blog is to share my experience and the cases I come across during this period.

This is an online E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent.

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

CASE

An 18 year old male patient came with complaints of tingling and numbness of both feet since 15 days, and both hands since 6 days.

Patient was apparently asymptomatic 15 days back, then when he had gone out to wash his feet, he noticed he could not feel the sensation of water flow. It was sudden in onset and gradually progressed up to the knee joint bilaterally. Followed by edema of both feet which was sudden in onset and gradually progressive, and increased on walking, and decreased on rest. Edema then subsided after 3 days without medication. 
Gradually he had difficulty wearing chappal since 10 days, which progressed to difficulty in climbing the stairs since 8 days, and difficulty squatting since 6 days. 
Later upper limbs also became involved, with an electric shock like sensation in both hands, distal muscle hand weakness since 5 days, and proximal hand weakness since 5 days. It was gradually progressive, and strength improved since 2 days. At the time he presented to the hospital, he was unable to walk or stand without support, unable to eat by himself, button his shirt, or comb his hair.

Neck muscle is normal
Rolling over on bed is normal
No h/o breathing difficulty
No diurnal variations
Limbs are flaccid and loose

No wasting/ thinning of muscle
No h/o pain, fatigue, muscle cramps, fasciculations, twitching of muscles, or involuntary movements.
He is able to feel cloth
Able to differentiate hot and cold water

He is having numbness, and sense of walking on cotton wool
No root pain, neck pain, back pain or band-like sensation.

No h/o vomiting, fever, loose stools, diarrhoea, sore throat, cough, chest pain, loss of consciousness, speech disturbances, delusions, or hallucinations.
No giddiness or palpitations.
Bowel and bladder intact.
no h/o DM, HTN, Epilepsy, CVA, TB, Thyroid
Sleep is normal.
No h/o smoking or alcohol intake. 

General examination:
Patient is c/c/c and oriented.
Moderately built and nourished
Pallor- absent
Icterus -absent
No cyanosis, clubbing, lymphadenopathy
Temp- afebrile
BP: 100/70 mm hg
PR: 54 bpm
CVS: s1 s2 heard, no murmurs
RS: BAE+ NVBS
P/A: soft, non tender

CNS:
Speech: normal
Cranial nerves , motor and sensory systems- intact
No cerebellar signs

Motor examination:

                                   Right                  Left
Bulk:
Inspection                    N                       N
Palpation                      N                      N

Tone:
UL                            Decreased       Decreased
LL                            Decreased       Decreased

Power:
Neck muscle             Good                  Good

Upper Limb- Shoulder: 
Flexion                        5/5                    5/5
Extension                    5/5                    5/5
Lateral rotaion           5/5                    5/5
Medial rotation          5/5                    5/5
Abduction                   5/5                    5/5
Adduction                   5/5                    5/5

Elbow:
Flexion (biceps)         5/5                    5/5
Extension (triceps)    5/5                    5/5

Muscles of forearm and wrist joint:
Ex. Carpi radialis      4/5                    4/5
Ex. Carpi ulnaris       4/5                    4/5
Ex. Digitorum            0/5                    0/5
Fl. Carpi radialis       0/5                    0/5
Fl. Carpi ulnaris        0/5                    0/5
Ex. pollicis brevis      0/5                   0/5
Ex. Pollicis longus     0/5                    0/5
Fl. Pollicis longus      0/5                    0/5
Abductor pollicis       0/5                   0/5
Adductor pollicis       0/5                   0/5
Opponens pollicis     0/5                    0/5
Lumbricals and
Interossius                 0/5                   0/5

Lower Limb:
Ilio psoas                    4/5                  4/5
Gluteus max.             5/5                  5/5
Adductor femoris      4/5                 4/5
Hamstrings                3/5                  3/5
Quadriceps                 4/5                 4/5
Tibialis ant.                0/5                 0/5
Tibialis post.               0/5                0/5
Peroneii                      4/5                 4/5
Gastrocnemius          4/5                  4/5
Ex. Digitorum L.        0/5                 0/5
Fl. Digitorum L.         0/5                 0/5
Ex. Hallucis L.           0/5                  0/5

Reflexes:
Superficial:
Abdominal                  +                     +
Cremasteric                 +                     +

Deep tendon reflexes:
Biceps:                          -                      -
Triceps:                        -                      -
Supinator:                    -                      -
Knee:                             -                     -
Ankle:                           -                      -
Plantar:                       m                    m
Sensory:
Crude touch                 +                     +
Pain                              +                     +
Temp.                            +                     + 
Fine touch                    -                      -
Vibration                      -                      -
Position                       -                         -

Videos of tone in this patient:

1. https://drive.google.com/file/d/1ptDs-IH2T6nxsZAF6MMePMiPhtzInAEv/view?usp=sharing




Reflexes in this patient:





Diagnosis: ?GBS Acute motor and sensory axonal neuropathy


Investigations :

Hemogram:
Hb.- 14.2 gm/dl
TLC- 6700 cells/cumm
Neutrophils- 60%
Lymphocytes- 27%
Eosinophils- 6%
Monocytes- 7%
Basophils- 0%
PCV- 40.3
MCV- 85.1
MCH- 29.9
MCHC- 35.1
RDW- CV- 14.5
RDW-SD- 47.4
RBC count- 4.74
Platelets- 2.52
Smear- normocytic normochromic RBCs


RFT:
Urea- 30 mg/dl
Creatinine- 0.8 mg/dl
Calc.- 10.3 mg/dl
Phosph.- 5.4 mg/dl
Sod.- 141 mEq/L
Pot.- 4.1 mEq/L
Chloride- 100 mEq/L
RBS- 74 mg/dl



LFT:
Total Bilirubin- 1.14 mg/ dl
Direct bilirubin- 0.56 mg/dl
SGOT( AST)- 23 IU/L
SGPT(ALT)- 15 IU/L
Alk. Phosphate- 305 IU/L
Total Proteins- 7.7 gm/dl
Albumin- 4.59 gm/dl
A/G- 1.48


HIV rapid test- negative
HCV- negative
HbsAg- negative


Treatment : 
Tab MVT OD
Tab Pan 40 mg OD
Monitor BP PR RR


Planning: Nerve conduction studies and review literature on biopsy in AIDP.

Observing the patient, there was no progression of symptoms. 
Over the next 2 days, this patient showed some improvement. He became able to walk slowly without support. His RR did not increase, suggesting respiratory muscles are also intact. 

Vidoe of his gait:
https://drive.google.com/file/d/1ruI_SlpMZ9uI-PDWd_odX7-rK6ULlBr8/view?usp=sharing


        We know that the pathology is in the nerves, specifically the peripheral nerves, but it is not clear which part of the nerve is involved (axon/ myelin sheath), or to what extent.  

The patient was sent for Nerve Conduction Studies to learn a little more about his condition.


The study was done, but came as not recordable, which suggested severe axonal damage. 
The report suggested Acute motor and sensory axonal neuropathy. 





We contemplated a nerve biopsy next, but as it would not effect the treatment, and thus an unnecessary expense, it was not done. 

Advice at discharge: 
1. Physiotherapy of all 4 limbs
2. Tab. B-complex OD

Majority of patients with GBS gradually improve on their own to a large extent if not fully. As this patient is already showing some improvement, we have hope that he will have a good recovery. 

Follow up after 2 weeks:
Patient showed slight improvement in hand muscles. Gait and power also showed improvement.





















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