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23.02.17
PATIENT PARTICULARS
Ashik Gharami
47 year , male
Muslim
CHIEF COMPLAINTS
Weakness of all 4 limbs-3yrs
Thinning all 4 limbs-3yrs
Tingling and paresthesia over fingers &
toes- 3yrs
Neck pain -3months
Insidious onset,gradually progressive
History of present illness
Patient was apparently well 3yrs back.To start with he
complained of weakness of all 4 limbs-insidious onset
,gradually progressive,involving distal part of both upper
& lower limbs.He found difficulty in mixing rice, holding
objects firmly,buttoning & unbuttoning shirts and holding
clothes for cutting. Initially he could do with difficulty,but
for last 2-3months,he is not able to do his job because of
the increased severity of weakness.
He also C/O slippage of chapals with awareness for the
same duration.
H/o difficulty in combing,doing overhead activities or
getting up from squatting posture since last 3months.
History of present illness(cont)
H/o neck and trunk weakness.
He found difficulty in lifting head from pillow and turning
sides on bed without assistance.
He also gives h/o thinning of all 4 limbs both proximal
and distal.
Significant weight loss (76kg previously,50kg at present).
Weakness was associated with looseness.
No h/o abnormal twitching,stiffness,flexor spasm.
No h/o diurnal variation
History of present illness(cont)
He complained of intermittent tingling pain over fingers and
toes after prolonged work/exertion.
No h/o burning ,cotton wool or plaster cast like sensation,or
numbness.
However,he C/O sharp,shooting pain over the upper
neck,radiating to both shoulder,down to dorso-lumbar spine
and up to left occipital region.These are not increased by
coughing,sneezing and movement,but precipitated by flexion
of head.pain has decreased in intensity at present.
He c/o unsteadiness of gait after prolonged walking and
difficulty while walking on uneven surface.Not increased at
evening hours.No visual or ear complain.No h/o fall,limb
tremulousness.
History of present illness(cont)
On direct quesioning,he complains of decreased
sweating over the body except the chest region.No h/o
hair loss,cold skin.
He gives h/o constipation for long time.
H/o loss of early morning erection for last 3yrs.
No history suggestive of bladder involvement,syncope.
No h/o diplopia,ptosis,dysphagia,nasal regurgitation of
liquid,nasal intonation of voice,facial asymmetry.
No h/o seizure,LOC,tremulousness,abnormal
posturing or fall.
History of present illness(cont)
On further questioning,he gave h/o tender skin
lesions over chest,trunk,back,left face,
proximal UL,rt LL.These are tender,slight
reddish appearance,no discharge,largest one
near rt axilla(noticed for last 2wks)
Family members noticed a swelling in posterior part of
neck on rt side.
H/O on and off fever(not documented)
No h/o rash,oral ulcer,joint pain, deformity.
No h/o respiratory distress,chest pain,palpitation.
No h/o drugs or toxin exposure
PAST HISTORY
Diagnosed as Type2DM for last 3yrs, on
medication
Normotensive
No thyroid illness,TB
H/O jaundice-30yrs back
H/O proptosis of left eye f/b double vision-
26yrs back,which recovered after
consulting Ophthalmologist.
PERSONAL HISTORY
Educated upto class 7th.
Occupation-Cutting clothes
No addiction
Mixed Indian diet
Married,2 daughter and 1 son
FAMILY HISTORY
No h/o similar illness in family members
Father died of Oral cancer
No major neurological illness in family members
SUMMARY
47year male,with 3yr h/o DM,nonHTN,
without any addiction presented with 3yr
h/o insidious onset,gradually progressive
weakness involving distal part of limbs and proximal
weakness for last 3months along with neck & trunk
weakness,associated with thinning & looseness.He had
tingling pain over fingers and toes,& sharp,shooting
pain over upper neck radiating to both shoulders,D-L
spine.He had generalised weight loss(26kg) and
papular,tender skin lesions over
chest,trunk,back,proximal UL,LL.H/O decreased
sweating ,erectile dysfunction and constipation.No
bldder involement .
ANATOMICAL SUBSTRATES
HMF-Conscious,oriented to time,place,person
Speech-normal
Comprehension-normal
CRANIAL NERVES
EOM-full
Pupil-B/L-NSNR
Fundus-CNBT (hazy media)
No facial asymmetry
No tongue weakness,atrophy,fasciculation
Palatal movement-B/L symmetrical
MOTOR:
BULK
RT LT
ARM 25CM 23.5CM
FOREARM 22CM 21.5CM
THIGH 35.5CM 34CM
LEG 28CM 27CM
Baseline BP-100/70 mm Hg
HR-100/min
STANDING:1min-110/80mmHg
3min-120/80mmHg (N)
Cold pressure (1min30sec)-DBP-90 (N)
Handgrip at 40mm Hg-DBP-70 (Abn)
SWEAT TEST- No sweating (Abn)
INVESTIGATIONS
Hb 7.6 UREA 17
ESR 145
TLC 5500 CREAT 1.12
DC N71L21M5 Na+ 125.9
B1
ALBUMIN 3.0
FBS 114
INVESTIGATIONS
ICTC-neg
HbSAg-neg
HCV-neg
PLEURAL FLUID
Cell-1380/c.mm
Mononuclear-37%,PMN-19%,
Mesothelial-44%(reactive)
Gramstain,AFB-neg
Protein-0.95g/dl
Sugar-125mg/dl
ADA-20
INVESTIGATIONS
BM ASPIRATION-Dry tap