GENERAL MEDICINE CASE DISCUSSION -A 18 YEAR OLD MALE PATIENT WITH BILATERAL LOWER LIMB WEAKNESS.
Entire case is present in the following link below:
https://hitesh116.blogspot.com/2020/05/12may-2020-elog-medicine-intern.html?m=1
A 18 year old male patient presented with
CHIEF COMPLAINTS:
1. Bilateral lower limb weakness since 20 days
HISTORY OF PRESENT ILLNESS:
The patient was apparantly asymptomatic 2 years back. Then he developed weakness which was insidious in onset and gradually progressive. It was initially proximal later progressed to distal. There was history of difficulty in squatting position and getting up from squatting position. Difficulty in wearing and holding chappals.
No history of difficulty in combing hair and buttoning& unbutoning shirt.
Associated with bilateral edema of lower limbs which was non pitting type.
No cranial nerve involvement
ON EXAMINATION :
Cranial nerves-intact
Higher mental functions -normal
Motor system-power decreased
Sensory system - normal
Reflexes-absent
My analysis from the history:
--It could be lower motor neuron lesion .
-In this; lesions can be present at different points .
-It could be at
*Anterior horn cell
*Dorsal root ganglion
*spinal nerve root
*Nerve
*Neuro muscular junction
*Muscle
From history i could make out that this is symmetrical ; motor issue ; no sensory involvement ; proximal part affected first .
--From this we can exclude ganglion; anterior horn cell; spinal nerve root as they are assymetrical lesions.
--In the history ; there were no complaints of fatiguability , fluctuating weakness or ocular problems they are the feature of neuro muscular lesions.
--The lesion could be nerve lesion because reflexes are absent and both proximal and distal muscles are involved.
--The lesion could be at the muscle . Because it is symmetrical lesion with motor involvement and proximal issue.
Weakness of muscle can be inherited or acquired.
DIFFERENTIAL DIAGNOSIS:
1. Inflammatory myopathy
2. Muscular dystrophy
3. Endocrine myopathy
4 . Drug induced myopathy
5.Demyelinating disorder- chronic inflammatory demyelinating polyneuropathy(CIPD)
--from histopathology exclude inflammatory cause.
--No history of usage of any drugs . So drug induced myopathy can be excuded.
--Thyroid profile for endocrine cause.
--On doing nerve conduction study ; it was found normal so CIPD can be excluded.
--For muscular dystrophy ; genetic testing shold be done to find any mutations.
In the history edema is present which may be due to cardiomyopathy which is common in duchenne or beckers muscular dystrophy
TREATMENT:
1. Steroids
2. Physiotherapy
3. Exercise
