A 55Y M with tingling sensation and weakness of Rt upper and lower limbs


1st July 2023

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

This is the case of a 55-year-old male, resident of Tirumalagiri, and Farmer by occupation. The following history was taken with the patient in person. The patient was explained about confidentiality and written consent was taken to create the following case report.


This case report aims to record the patient's journey.

CHIEF COMPLAINTS:- 

1. Tingling sensation in Rt upper and lower limbs since 29th June

2. Weakness in the Rt upper and lower limbs since 29th June

History of present illness:- 

Pt was apparently asymptomatic before 29th of June, afterwhich he then developed weakness of Right upper and lower limbs which is described to be insidious in onset (1st the right leg was affected), gradually progressive in nature. Weakness is associated with tingling sensation. Every one hour this tingling sensation is noticed. This sensation aggrevates during the night. There are no noted relieving factors. The patient faces difficulty in standing and walking by himself. Slipping of chappals present while walking. However there is no tripping of toes. The patient also faces difficulty in taking in food, combing hair and buttoning up his shirt by himself. 

The patient is able to feel clothes but wasn't able to differentiate between hot and cold sensation as well as feel the pin and needle sensation. Slurring of speech was present. 

 Decreased hearing in both the ears since 10 years. 

Daily routine
The patient wakes up at 6am. Follows a sedentary lifestyle. Has three meals. Has proper sleep (without any disturbance). 

Negative history

No c/o deviation of mouth , loss of consciousness, headache, giddiness, vomitings, Pain
 
No H/o involuntary passage of urine or stools 
No H/o fever , loose stools , sob , pain abdomen. 

No h/o visual disturbances, headache, diplopia, ptosis, he is able to appreciate smell, he is able to look towards all sides no h/o sensory loss over the face, no facial deviation. 

No noted sensory deficit as the patient was able to feel clothes, feeling hot and cold water while bathing. 

No h/o auditory disturbances

No h/o restricted tongue movements

No difficulty in swallowing

No difficulty in speaking

No h/o abnormal sweating

No h/o shooting pain

No h/o headache or vomiting.

No h/o seizures

No h/o Fasciculations/muscle twitchings.

No h/o Involuntary movements like chorea, athetosis, hemiballismus

-------------------------------

History of past illness:-

The patient does not have any history of TB, DM, Epilepsy and asthma. 

The patient is a k/c/o of HTN since 4-5 months, used medication (unknown) for 2 months and then stopped. 

No h/o of past illnesses or surgery. 

Personal history:-

Water intake:- normal

Appetite:- normal

Diet:- mixed 

Bowel movement:- normal

Bladder movement:- normal

Alcohol:- stopped alcohol 8 months back. 

Smoking:- stopped smoking 8 months back. 

Addiction:- nil

Allergies:- nil

Exercise status:- nil

FAMILY HISTORY:-

- Patient parents were in a consagiunius marraige. 

- Patients father has faced the similar symptoms. 

PHYSICAL EXAMINATION:-

GENERAL EXAMINATION:-

The examination was conducted at a well lit and well ventilated room. The patient was conscious, cooperative and coherent. 

Moderately built

Afebrile

No Palor

No Icterus

No Cyanosis

No Clubbing 

No Pedal edema

No Significant lymphadenopathy

CNS EXAMINATION:-

Bulk  

                          rt         lf

Arm             23 cm    23cm

Forearm      24cm      24cm

Leg              29cm      29cm


Tone

                               rt                      lf

Arm                   increased      normal

Leg                    increased     normal


Power

                                   rt                 lf

Upper limb                4/5              5/5

Lower limb                4/5               5/5

-Hemiplegic gait

Cerebellar signs

No coordination seen in finger nose test. 

No coordination seen in knee heel test. 

CLINICAL PICTURES:-


REPORTS:-


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