22 yr old man with difficulty in walking and sitting without support since 2 months....
This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
22 year old man from Singaram presented with the complaints of
Difficulty to walk without support since 2 month
Difficulty to sit without support since 2 months
He was born out of a non consanguineous marriage. His father works as a coolie at Singaram village. He is third in birth order. He has an elder brother and sister who are married. He was delivered through normal vaginal delivery at home by a local RMP practitioner. He did not cry immediately after birth, he cried on his 21st day after birth according to his mother. He passed meconium within 24hours.
At 4 months of age, he had his first episode of GTCS lasting for 3 minutes.
All his developmental milestones are delayed:
He attained neck holding at 7 months of age
Rolling to the side at 9 months of age
At 1 year of age, he started sitting with support and started smiling at familiar faces
His mother started him on homeopathic medications as he did not start crawling even at 1 year of age and her sisters son by then would stand and walk with support.
At 5 years of age he started to walk without support and starting to utter only the term 'Amma'.
His mother tells us that he is able to understand what others are saying and uses gestures in response but the only term he utters is Amma.
She also tells that she helps him in taking a bath, feeding him or dressing him. She also tells that he spills half of the water or food that is fed to him.
But he does go to local shops by himself and would operate mobile by himself.
He hasn't received any vaccinations.
Since he was 10 years of age, he again started having recurrent episodes of GTCS, atleast once in every 3 months. He was started on Tab Phenytoin 100mg twice daily.
2 months back, at his brothers wedding after eating chicken he suddenly developed difficulty in walking and hasn't been able to even sit without support since then.
H/o difficulty in swalloing since 1 month both to solids and liquids.
Treatment history:
Chronic phenytoin usage >10yrs
Family history:
No similar complaints in the family
Maternal hypothyroidism present
General examination
Pt is conscious
Palor -
Icterus-
Cyanosis-
Clubbing-
Lymphadenopathy-
Pedal oedema-
Vitals
Temp afebrile
Pr:88bpm
RR:18cpm
Bp:100/50mmhg
Oral cavity:gum hyperplasia present
CNS
Higher mental functions:
Speech monosyllable only utters the term Amma
Orientation:not oriented to time,place,oriented to person
Memory:unable to recall immediate,recent and remote memory
No signs of meningeal irritation
Cranial nerves: couldn't be elicited
Motor system:
Increases Tone in all muscles
Power UL. 3/5
LL 3/5
B/l grade 4 reflexes,spasticity present in all examined muscles
Muscles. Right. Left
Biceps. 3+. 3+
Triceps. 3+. 3+
Supinator. 3+. 3+
Knee. 3+. 3+
Ankle. 4+. 4+
Clonus. B/l present
Sensory system: unable to elicit
Cerebellar system: unable to elicit
CVS:
soft S1,split S2
Crescendo decrescendo murmurs best heard in aortic area grade 3 increased on end expiration leaning forward
Respiratory
Shape of the chest:pectus excavatum
Trachea:shifted to left,NVBS,no added sounds
