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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