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72M CIDP 3years

 


A 72-year-old male, hailing from Gurramudu mandalam, was born into a family of 7 siblings. He achieved typical developmental milestones during his upbringing. Fond memories characterize his childhood. He commenced farming at the age of 15, deviating from the family's pottery background to a farming tradition spanning several generations.


Two decades ago, his father passed away a year after experiencing a cerebral vascular accident (stroke). The patient entered into a consanguineous marriage four generations deep within his family tree. Three years ago, while tending to his agricultural duties, he suddenly experienced abrupt onset bilateral calf pain. Subsequently, he sought medical attention at a local hospital where he was admitted for a week and underwent treatment. His symptoms subsided, leading to his discharge.


Three months later, he encountered similar discomfort, after which he began relying on a walking aid. Three years ago, the patient presented with chest pain characterized by a dragging sensation that radiated to his left arm. Accompanying symptoms included breathlessness and palpitations. An immediate hospital visit led to the diagnosis of coronary artery disease (CAD). Percutaneous transluminal coronary angioplasty (PTCA) was performed. Concurrently, he was diagnosed with hypertension and commenced on antihypertensive medications.


The patient's lower limb weakness progressively worsened. It initiated as difficulty with walking, necessitating the use of a walking stick for a year. Subsequently, reliance shifted to a walker, followed by an inability to cycle, then to difficulty in donning slippers, and currently, an inability to grasp objects like slippers.


His pre-illness daily routine included rising at 5 am, engaging in buffalo milking, followed by tea consumption. Farm work commenced at 6 am, with a return home at 9 am for a breakfast of rice and curry. Field labor recommenced at 10 am, with a lunch break from 2 pm to 6 pm, culminating in retiring to bed at 8 pm. The fields were located in proximity to his residence.


Post-illness, his daily regimen shifted drastically. Limited outdoor movement ensued. Rising at 6 am, he would take short walks with a walker, followed by personal grooming and the utilization of an Indian-style washroom. Morning hours were occupied by tea consumption, television watching, and brief naps until 11 am. Brunch was consumed at 11 am, while dinner occurred at 7 pm, and bedtime at 9 pm.



ABDOMINAL CIRCUMFERENCE : 108cms

STRESS RESILIENT 

Resilience Questionnaire

1. In a difficult spot, I turn at once to what can be done to put things right. 

2. I influence where I can, rather than worrying about what I can’t influence.

3. I don’t take criticism personally.

4. I generally manage to keep things in perspective.

5. I am calm in a crisis.

6. I’m good at finding solutions to problems.

7. I wouldn’t describe myself as an anxious person.

8. I don’t tend to avoid conflict.

9. I try to control events rather than being a victim of circumstances. 10. I trust my intuition.

11. I manage my stress levels well.

12. I feel confident and secure in my position.

TOTAL

Score

                          


CNS Examination:

Higher mental functions:

Patient is conscious oriented to time place and person 

Speech and language :Normal

Memory :intact( Recent,Immediate,Remote)

Hallucinations -absent


GAIT

https://youtube.com/shorts/pYsECZ1nC4o?si=dSYaE45kNbCwN-0s

https://youtube.com/shorts/c5Wb6ilDKVo?si=Lj5rjuhYK_uO9mcS

Cranial Nerves:

CN -1:

Sense of Smell - Normal 


CN-2: Normal


CN-3:                                Right                Left

i)EOM movement -          Full                     Full

ii)Direct Light Reflex-      present.           present

iii) Consensual Light Reflex present       Present 

iv) Accommodation Reflex   present      present

v)Ptosis                              Absent            absent 

CN 5:

Sensory over face & buccal mucosa - Normal on both sides

Motor - masseter, Temporalis:Normal

Reflexes - Corneal,Conjunctival Normal.

CN-7

No Deviation of Mouth

Motor:

Nasolabial fold -present on  both sides

Occipito frontalis - Good

Buccinator - Good.

Sensory: Normal

CN-8:

Rinne test positive in both ears

Weber test centralised 

CN-9 and 10 :Uvula,palatal arches movements -Normal 

Gag reflex - N

CN-11:intact

CN-12:intact


Motor System:

Bulk:

Upper limbs:Normal

Lower Limbs:Normal


Tone:

Upper limbs:Normal

Lower Limbs:Normal


Power:               Right.        left

Upper Limb       5/5             5/5

 Lower Limb      3/5.            4/5


Reflexes:          Right           Left

Biceps:               1+                1+

Triceps:              1+                 1+

Supinator:          1+                    1+

Knee:                Absent         absent 

Ankle:                Absent        absent

Planter:              Mute           Mute


Sensory system:


                               Right.                 Left 

Crude touch :    

Upper Limb            Present.             present

Lower Limb           Present               Present 


Pain :

Upper Limb            Present.             present

Lower Limb           Present               Present 


Fine touch:

Upper Limb            Present.             present

Lower Limb           Present               Present 


Vibration: 


Upper limb:              Right.                    Left

1) Styloid:      Present(6.7 sec)         present(6.9 sec)

2)olecranon process:present (7.3 sec) present (7.1 sec)

3)Acromion process:present(10.2 sec) present(9.6 sec)


Lower Limb :

1) Tibial tuberosity : can’t sense vibration 

2)Shaft of Tibia:can’t sense vibration 

3)Medial Malleolus:can’t sense vibration 


Position sense:      

                                   Right             Left

Upper Limb              10/10           10/10

Lower Limb              5/10              4/10

-Graphaesthesia-Postive

-Stereognosis-Positive


Cerebellar signs:

-Titubation:absent

-Nystagmus:absent

-Dysarthria:absent

-Hypotonia:absent

-Intention tremor:absent

-Coordination

a.Finger Nose test: Normal 

b.Heel Knee test:Impaired 


Investigations:

NCS shows reduced motor conduction velocity in Right median nervewith conduction Block and reduced motor conduction velocity in left mediam Newe. There is conduction block across right ulnar nerve.Absent MUAPS  in Bilateral peroneal nerve and reduced CMAP in B/L TibialNerves . sensory conductions show absent SNAP in Right median nerve with absent SNAP in Bilateral sural nerves.

Features S/o sensory motor Demyelinating Neuropathy with conduction Block.


25/08/23

Haemoglobin:13.1g%

Red blood cells:4.38million/mm3

Pcv:32.7%

Platelet count:2.04lakhs/mm3

Total leucocyte count:8,700/mm3


25/08/23

Blood urea 32mg/dl

Sr creatinine 1.0mg/dl

serum Na 145mmol/dl

Serum K 4.4mmol/dl

Serum Cl 102mmol/dl


25/08/23

Total bilirubin:o.87mg/dl

Direct bilirubin: 0.19mg/dl

Indirect bilirubin:1.5mg/dl

Alkaline phosphatase:168 IU/L

SGPT:21 IU/L

SGOT:15 IU/L

Protein total: 6.9G/DL

Albumin:4.12g/dl

Albumin and globulin ratio:1.4


DIAGNOSIS

CIDP


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