40 Year old man with dyspnoea, pedal edema and paralysis

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/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.

Here is a case i have seen:

40 year old man, farmer by occupation presented to the opd with the complains of 

Bilateral pedal edema since 20 days 

Dyspnea on exertion since 18 days

Tingling and numbness in lower limbs  since 1 week followed by tingling and numbness in his left forearm which he developed over the next 5 days

Unable to hold chappal since 1 week

Difficulty in grasping objects since 1 week 

He even says his voice has changed over the last 1 week 

Patient works as a farmer and got married to a daily labourer 12 years back. He has 2 kids, one son and a daughter. Son is in his 6th class and his daughter is in 2nd class. He is an Occasional alcoholic since 10 years, last intake was 1 month back. He used to smoke everyday 10 years back, 2-3 cigarettes per day. He was apparently alright 20 days back then he developed bilateral pedal edema extending to thigh followed by that he developed dypnea on exertion, he started feeling dyspneic even on walking short distances. He then paid a visit to Nalgonda hospital where he was put on certain medications which releaved his lower limb swelling, he was told that he had a kidney problem. Later he visited Bhongir hospital twice for the same complains where he was put on syp potchlor, T  telma H, Lasix, Gabapentin, Myochase. Since a week he has been experiencing pain in both the lower limbs, he first realized this while he was sitting in his chair 1 week back. Over the last few days he found it difficult to hold his chappal. He started experiencing tingling and numbness in both his lower limbs along with his left forearm. He started finding it hard to grasp objects with his left hand. He says he feels his voice has changed over the last 1 week.

No significant past history/ drug history/ family history. 

He also has hypopigmented lesions over his abdomen, right axillary region. He says he has been having those since childhood.

GENERAL EXAMINATION 

patient is conscious, coherent ,cooperative obese built and nourished

Gait - waddling gait

VITALS

BP - 170/120mmhg

Pulse- 88 bpm

Temp- afebrile

Spo2- 98% at room air

RR- 21cycles /min

No pallor, icterus, cyanosis, clubbing and lymphadenopathy 

Hypopigmented patches over abdomen, thigh and axilla region

SYSTEMIC EXAMINATION 

CNS EXAMINATION 

Higher motor functions are normal

All cranial nerves intact

MOTOR SYSTEM 

Bulk:                           RIGHT           LEFT

Mid thigh                     24 cms           24cms

Mid calf                       13 cms.          13cms

Mid arm                       10 cms.          10.5cms

Mid Forearm                8 cms.            8.5cms

TONE                   

Upper limb                  Normal.          Normal

Lower limb                  Decreased.     Decreased

POWER:

Deltoid                                  5/5.                 5/5

supra spinatus                       5/5.                 5/5

serratus anterior                    5/5.                 5/5

Infra spinatus                        5/5                  5/5                

Rhomboid                             5/5.                 5/5

Pectoralis major                    5/5.                 5/5

Latissimus dorsi                    5/5                  5/5

Biceps                                   5/5                  5/5

Brachioradialis                     5/5                  5/5

Triceps                                  5/5.                 5/5

Extensor carpiradialislongus3/5                  2/5

Extensor carpi ulnaris.          5/5                  5/5

Extensor digitorum               4/5                  0/5

Flexor carpi radialis              5/5                  5/5

Flexor carpi ulnaris               5/5                  5/5

Abductor pollicis                   2/5                  2/5

Extensor pollicis brevis         0/5                  0/5

Extensor pollicis longus        0/5                  0/5

Opponen pollicis.                  5/5                  5/5

Abductor pollicis brevis       4/5                  3/5

Flexor pollicis longus            5/5                  4/5

Adductor pollicis                   4/5                  4/5

Lumbricals                            5/5                  3/5

Interossei.                              4/5                  3/5

Iliopsoas.                               5/5                  5/5

Adductor femoris                5/5.                  5/5

Quadratus femoris              5/5                  5/5

Gluteus medius and.           5/5.                 5/5

minimis                                 5/5                 5/5

Gluteus maximus                  5/5.                5/5

Hamstrings.                           5/5                 5/5

Tibialis anticus                     -4/5.             +4/5

Tibialis posticus                    5/5                 5/5

Peronei                                  0/5                 0/5

Gastronemius                        5/5                 5/5

Extensor digitorum longus    0/5                 0/5

Flexor digitorum longus       5/5                 5/5

REFLEXES            RIGHT            LEFT                    

 Biceps                    Absent.             Absent

 Triceps                   Absent.             Absent

 Supinator               Absent              Absent

 Knee.                     Absent.             Absent

 Ankle.                    Absent.             Absent

Plantar.                   flexion              Flexion

SENSORY EXAMINATION - intact

CEREBELLAR SIGNS

nystagmus-absent

Rombergs test- negative 

CVS EXAMINATION 

S1 S2 heard

No murmurs

RESPIRATORY EXAMINATION 

bilateral air entry present

No added sounds

PERABDOMEN EXAMINATION 

mildly distended

Umbilicus inverted

No organomegaly

Bowel sounds heard

His hypopigmented patches

When he FIRST came to OPD 

                                    HIS GAIT

HIS MOTOR EXAMINATION 

ECG- sinus tachycardia present

His 2D ECHO

Serology for HCV, HIV, HBSag was done which was found out to be negative

ON THE DAY OF ADMISSION (DAY 1)

                                        

GAIT 

                              

Rombergs test

DAY2

40 year old man 

With Peripheral neuropathy 

? AIDP

Isn't giving consent for endoscopy even after clearly explaining 

PR - 85 bpm

Bp - 170/120mmhg

Afebrile

Cvs - s1,s2 

Lungs - clear 

We've given him Tab Nicardia 20mg as of now

Even in the opd when he presented his BP was 140/90mmhg and he was prescribed Tab telma by a doctor from outside hospital 

So we are planning on monitoring his bp and will start him on tab telma 40mg if needed

DAY 3

He says he can walk better 

His PR - 80bpm

Bp - 150/100

Cvs - s1,s2 +

Lungs - clear 

We've started him on Telma 40mg OD