27YEAR OLD MALE WITH LOW BACK ACHE,PERIODIC WEAKNESS OF LOWER LIMBS AND TINGLING OF HANDS SINCE 6 YEARS
Treating Team
Interns
Dr Mohitha
Dr Supriya Reddy
Dr. Sowmya Kota
Dr. Amrutha
Dr Sanjay
PGY1-Dr Durgakrishna
PGY2-Dr Ajith
PGY3-Dr Laxma Reddy
Dr Manasa
Faculty- Dr Vijaya Lakshmi
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A 26yr male who is a farmer by occupation resident of West Bengal..came with c/o of pain in the both upper and lower limbs ... Tingling and numbness in both limbs..since 5yrs.
HOPI : pt was apparently asymptomatic 5 years back and developed pain in the small joints of left Upper limb followed by involvement of small joints of Right upper limb followed by involvement of Other joints and spine with in 2-3 days ...pt went to the local hospital where few imaging and investigations performed which showed that he is suffering from Spondyloarthropathy( but no reports available at that time..only proof was doctors prescription)...so he was started on few drugs for 15 days followed by Tab Sulfasalazine 1gm PO/BD..daily..With this .pt was doing well ..no other complaints.. aggravating factors are alcohol intake and Stoppage of Sulfasalazine for2- 3 days ....But in the last 3 -4 months..eventhough with Sulfasalazine patients pain was not reducing ..so he came to KIMS for further evaluation.
Past history: K/C/ O Ankylosing spondylitis since 3yrs
Personal history': Started eating Gutka since 3 years.
Stopped schooling at 9th class...married at 26 years of age...Known alcoholic since 17 years, frequency of 2-3 times in a month , consumes 300ml of whisky or 2 bottles of beer in one sitting. He attributes that alcohol intake increase his symptoms and abstinence doesn’t relieve though.
O/E
Patient is conscious , coherent ,cooperative,oriented to time place and person.
No pallor, icterus,cyanosis,clubbing,lymphadenopathy,pedal edema
VITALS
Temp- afebrile
BP-140/100mm hg
PR-92bpm
RR-16cms
SYSTEMIC EXAMINATION
CVS- s1 ,s2 +
RS- B/lAE +,NVBS+P/A- soft , non tender, no organomegaly
CNS
HIGHER MENTAL FUNCTIONS-are intact
All CRANIAL NERVES are intact
MOTOR SYSTEM
1) Nutrition - normal
Anthropometry
Left Right
Mid arm 29 cms Mid arm 28cms
Mid forearm 24cms Mid Forearm 25cms
Left Right
Mid leg 34cms Mid leg 34cms
Mid thigh 45cms Mid thigh 44cms
2) Tone - Both upper limbs and lower limbs tone normal
3)Power- 5/5 in both upper and lower limbs
4)Reflexes
Superficial reflexes- intact
Deep tendon reflexes- absent except left biceps
SENSORY SYSTEM
Spinothalamic- intact
Dorsal column - intact
Cortical sensations -intact
CEREBRLLAR FUNCTION TEST
Finger nose test-normal
Knee heel test-normal
Dysdiadokokinesia-normal
Chest expansion -2cms noted
MODIFIED SCHOBER TEST-4cms of lumbar flexion noted
LATERAL BENDING TEST-on left side 14cms
and on right side 11cms
TREATMENT
1)TAB PREGAB-NT /PO/OD/HS
2)TAB INDOCAR-SR/PO/BD
3) TAB ZINCOVIT/PO/OD
Psychiatry Refferal:
NCS DONE ON 30/1/21
Date: 1/2/2021 SOAP notes update:
S- Patient is subjectively feeling better.
Pain has subsided. He is able to walk normally.
O- BP 140/90mmhg
PR- 104bpm
CVS -s1s2 +
Rs -BAE +
P/A -soft ,non tender
A- NCS done- bilateral sensory motor axonal neuropathy of upper limbs
P- Tab. Pregabalin PO/OD /H/S
Tab. Neurobion forte PO/OD
Tab. Zincovit PO/OD
Date:2/2/2021 SOAP NOTES UPDATE
26M with periodic weakness of lower limbs with tingling and pain in hands and small joints.
Known alcoholic since 17 years, frequency of 2-3 times in a month , consumes 300ml of whisky or 2 bottles of beer in one sitting. He attributes that alcohol intake increase his symptoms and abstinence doesn’t relieve though.
CNS findings
Tone : normal in all the limbs
Power : both upper limbs normal
Lower limbs power 4/5 both lower limbs
Deep tendon reflexes - absent in all limbs
Superficial reflexes intact.
Sensory :
fine touch intact in all limbs
Vibration decreased in all limbs of approximately 5 sec compared to examiners
Cerebellar functions normal.
