case 22 - 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.

Here is a case i have seen:

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




P/A :soft,non tender
Diagnosis:
Cerebral palsy with recurrent GTCS
Day 1
Investigations:









Treatment
 1.inj.thiamine 1amp in 100ml.NS 2PM before lunch
2.IVF RL 1unit @100ml/hr with 1amp optineuron
3.Tab.Dicorate sodium 250mg/po/bd

Day 2


Treatment
 1.inj.thiamine 1amp in 100ml.NS 2PM before lunch
2.IVF RL 1unit @100ml/hr with 1amp optineuron
3.Tab.Dicorate sodium 250mg/po/bd
4.Tab.zerodol.p po od 2pm
 
Day 3

Treatment
1.inj.thiamine 1amp in 100ml.NS 2PM before lunch
2.IVF RL 1unit @100ml/hr with 1amp optineuron
3.Tab.Dicorate sodium 250mg/po/bd


Day 4:
1.inj.thiamine 1amp in 100ml.NS 2PM before lunch
2.IVF RL 1unit @100ml/hr with 1amp optineuron
3.Tab.Dicorate sodium 250mg/po/bd
4.Tab.Dolo 650mg TID
5.Tab.Pantop 40mg/of/iv
6.inj.Zofer 4mg/Tid/IV







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