37M with B/L Lower limb weakness


 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

37 year old male patient farmer by occupation, resident of bardipur, Nizamabad presented with chief complaints of 
loose stools since 3-4 days
nausea and vomiting's since 3 days 
both lower limb pain and weakness since 2 days
difficulty in walking since 1 day.

Patient was apparently normal 4 days back then he developed loose stools 3-4 episodes, watery consistency, associated with nausea and vomiting's with food particles as contents. since 2 days patient had both lower limbs weakness and pain worsened over a day to walking with support. tingling sensation of both upper and lower limbs present.


O/E
Pt conscious, oriented to time place person.
Gcs= E4V5M6
HR - 73bpm
BP - 140/90 mmhg
RR - 18 cpm
TEMP - 98.3 F
GRBS - 97 mg/dl
SPO2 - 99% RA

GAIT : Broad based gait with Ataxia requiring 1 person support to walk or balance. ?lateropulsion, truncal ataxia.


Tone :
Rt upper & lower limb normal
Lt lower limb & upper limb normal.

Power - as patient was confused she didn’t obey commands thus couldn’t be elicited.

Reflexes - all upper and lower limb reflexes are absent
b/l plantars - mute


all other systems are unremarkable.

with this findings neurophysician opinion was taken for further evaluation and treatment.

Day 3

  • Chief Complaint: Patient presented with complaints of progressive weakness.

  • Clinical Impression: Suspected acute inflammatory demyelinating polyneuropathy (AIDP).

  • Neurological Examination:

    • Lower limb weakness (bilateral).

    • Diminished reflexes in bilateral lower limbs.

  • Investigations Ordered: Cerebrospinal fluid (CSF) analysis.

CSF:

  • CSF (Cerebrospinal Fluid) Analysis:

    • Quantity: 6 mL (Normal)
    • Color: Colorless (Normal)
    • Appearance: Clear (Normal)
    • Coagulum: None (Normal)
    • pH: 6.8 (Normal)
    • Glucose: 67.6 mg/dL (Normal: 45 - 80 mg/dL)
    • Proteins: 290.51 mg/dL (Abnormal, Normal: 15 - 45 mg/dL)

Day 4

  • Progress: Neurological symptoms persisted with worsening motor function.

  • CNS Examination:

    • Lower limb examination: Weakness present, bilateral reduced muscle power.

    • Upper limb examination: Weakness noted, more prominent distally.

    • Deep tendon reflexes: Depressed in bilateral lower limbs.

    • Sensory Examination: No significant loss detected.

  • Management Plan:

    • Initiation of IV immunoglobulin (IVIG)  considered.

    • Monitoring for respiratory compromise.

Day 6

  • Clinical Course:

    • Persistent lower limb weakness.

    • Ongoing difficulty in ambulation.

  • Neurological Status:

    • Hand grip strength: Reduced to 40% bilaterally.

    • Hip flexion: Markedly weak.

    • Reflexes: Diminished.

    • Autonomic Signs: Mild dysautonomia suspected.

  • Vitals:

    • Pulse Rate: 81/min.

    • Blood Pressure: 140/96 mmHg.

  • Plan:

    • Continue supportive care.

    • Further electrophysiological studies considered for confirmation of demyelinating neuropathy.



Day 8

  • Neurological Re-evaluation:

    • Hand grip strength remained weak.

    • Quadriceps weakness (3/5 power).

    • Hip extension remains weak.

  • Final Assessment: Likely acute inflammatory demyelinating polyneuropathy (AIDP).

  • Plan:

    • Ongoing physical rehabilitation.

    • Symptomatic treatment and monitoring.


Day 10

  • Provisional Diagnosis: Acute Neurological Deficit (ANP) with probable motor weakness
  • Neurological Examination:
    • Right Lower Motor Neuron (LMN) involvement
    • Gait abnormality
    • Neck flexion affected
    • Reflexes:
      • Biceps and triceps: Upper limb involvement
      • Hip flexion: 3/5
      • Knee extension: Bilateral 3/5
      • Ankle dorsiflexion: Reduced bilaterally (3/5)
    • Extensor reflexes and lower limb strength appear reduced
    • Special Note: Weakness noted in the Extensor Hallucis Longus (EHL) 
  • Referral to Ophthalmology
  • Findings:
    • Mild temporal conjunctival congestion
    • Inflammatory markers noted
    • Pupil examination suggests possible early optic neuritis
    • Foreign body removal from left eye performed
  • Management Plan:
    • Artificial tears (Refresh Tears) 4 times/day
    • Lubricant drops (Hyaluronic acid-based) 4 times/day for 1 week, then 2 times/day

Day 11

  • Findings:
    • Chin and neck flexion weakness persist
    • Handgrip: 40% of expected strength
    • Bilateral hip flexion remains weak
    • Biceps reflexes at 3/5
    • EHL remains weak
    • Ankle dorsiflexion and plantar flexion remain weak



LABS : Here is the detailed day-wise summary of the lab results with normal and abnormal values highlighted:

Day 1:

Liver Function Tests (LFT):

  • Total Bilirubin: 0.9 mg/dL (Normal: 0.1 - 1.2 mg/dL)
  • Direct Bilirubin: 0.2 mg/dL (Normal: 0.00 - 0.30 mg/dL)
  • Indirect Bilirubin: 0.7 mg/dL (Normal: 0.00 - 0.90 mg/dL)
  • ALP (Alkaline Phosphatase): 74.5 U/L (Normal: 41 - 137 U/L)
  • SGOT (AST): 347.1 U/L (Abnormal, Normal: < 45 U/L)
  • SGPT (ALT): 446.3 U/L (Abnormal, Normal: < 45 U/L)
  • Protein: 7.9 g/dL (Normal: 6.0 - 8.3 g/dL)
  • Albumin: 4.1 g/dL (Normal: 3.2 - 5.0 g/dL)
  • Globulin: 3.8 g/dL (Abnormal, Normal: 1.8 - 2.5 g/dL)
  • Ratio: 1.0 (Normal: 0.6 - 2.0)

Renal Function Tests (RFT):

  • Blood Urea: 18 mg/dL (Normal: 13 - 45 mg/dL)
  • Serum Creatinine: 1.1 mg/dL (Normal: 0.6 - 1.5 mg/dL)
  • Electrolytes:
    • Sodium: 141 mmol/L (Normal: 135 - 150 mmol/L)
    • Potassium: 4.6 mmol/L (Normal: 3.5 - 5.5 mmol/L)
    • Chloride: 107 mmol/L (Normal: 95 - 110 mmol/L)

Hematology:

  • Hemoglobin: 13.4 g/dL (Normal Female: 11.5 - 15.5, Male: 12.5 - 17.0 g/dL)
  • RBC Count: 5.4 million cells/cumm (Normal: 4.0 - 6.2 million cells/cumm)
  • WBC Count: 5,600 cells/cumm (Normal: 4,000 - 11,000 cells/cumm)
  • Platelet Count: 2.48 lakhs/cumm (Normal: 1.5 - 4.5 lakhs/cumm)
  • Hematocrit (PCV): 44.9% (Normal: 35 - 50%)
  • MCV: 82.5 fl (Normal: 80 - 100 fl)
  • MCH: 24.6 pg (Abnormal, Normal: 26 - 34 pg)
  • MCHC: 29.8 g/L (Abnormal, Normal: 31 - 35 g/L)

Differential Count:

  • Neutrophils: 66% (Normal: 40 - 70%)
  • Lymphocytes: 24% (Normal: 20 - 40%)
  • Eosinophils: 4% (Normal: 2 - 6%)
  • Monocytes: 6% (Normal: 1 - 6%)
  • Basophils: 0% (Normal: 0 - 1%)

Thyroid Stimulating Hormone (TSH):

  • TSH: 5.87 mIU/mL (Abnormal, Normal: 0.3 - 4.2 mIU/mL)

Microscopic Examination:

  • Total Cell Count: 6 cells/cumm (Normal)
  • Differential Count:
    • Neutrophils: 50%
    • Lymphocytes: 50%
    • Eosinophils: 0%
    • Monocytes: 0%
    • Basophils: 0%

Day 3:

Liver Function Tests (LFT):

  • Total Bilirubin: 0.6 mg/dL (Normal: 0.1 - 1.2 mg/dL)
  • Direct Bilirubin: 0.3 mg/dL (Normal: 0.00 - 0.30 mg/dL)
  • Indirect Bilirubin: 0.3 mg/dL (Normal: 0.00 - 0.90 mg/dL)
  • ALP: 55 U/L (Normal: 41 - 137 U/L)
  • SGOT: 444 U/L (Abnormal, Normal: < 45 U/L)
  • SGPT: 997 U/L (Abnormal, Normal: < 45 U/L)
  • Protein: 6.5 g/dL (Normal: 6.0 - 8.3 g/dL)
  • Albumin: 3.9 g/dL (Normal: 3.2 - 5.0 g/dL)
  • Globulin: 2.6 g/dL (Abnormal, Normal: 1.8 - 2.5 g/dL)
  • Ratio: 1.5 (Normal: 0.6 - 2.0)

Renal Function Tests (RFT):

  • Blood Urea: 21 mg/dL (Normal: 13 - 45 mg/dL)
  • Serum Creatinine: 0.9 mg/dL (Normal: 0.6 - 1.5 mg/dL)

Hematology:

  • Hemoglobin: 11.4 g/dL (Normal Female: 11.5 - 15.5, Male: 12.5 - 17.0 g/dL)
  • RBC Count: 4.7 million cells/cumm (Normal: 4.0 - 6.2 million cells/cumm)
  • WBC Count: 8,900 cells/cumm (Normal: 4,000 - 11,000 cells/cumm)
  • Platelet Count: 3.40 lakhs/cumm (Normal: 1.5 - 4.5 lakhs/cumm)
  • Hematocrit (PCV): 38.9% (Normal: 35 - 50%)
  • MCV: 82.4 fl (Normal: 80 - 100 fl)
  • MCH: 24.2 pg (Abnormal, Normal: 26 - 34 pg)
  • MCHC: 29.3 g/L (Abnormal, Normal: 31 - 35 g/L)

Differential Count:

  • Neutrophils: 79% (Abnormal, Normal: 40 - 70%)
  • Lymphocytes: 15% (Abnormal, Normal: 20 - 40%)
  • Eosinophils: 3% (Normal: 2 - 6%)
  • Monocytes: 3% (Normal: 1 - 6%)
  • Basophils: 0% (Normal: 0 - 1%)

Thyroid Stimulating Hormone (TSH):

  • TSH: 5.87 mIU/mL (No change from Day 1)

CSF:

  • CSF (Cerebrospinal Fluid) Analysis:

    • Quantity: 6 mL (Normal)
    • Color: Colorless (Normal)
    • Appearance: Clear (Normal)
    • Coagulum: None (Normal)
    • pH: 6.8 (Normal)
    • Glucose: 67.6 mg/dL (Normal: 45 - 80 mg/dL)
    • Proteins: 290.51 mg/dL (Abnormal, Normal: 15 - 45 mg/dL)

Day 4:

Liver Function Tests (LFT):

  • Total Bilirubin: 0.8 mg/dL (Normal: 0.1 - 1.2 mg/dL)
  • Direct Bilirubin: 0.4 mg/dL (Abnormal, Normal: 0.00 - 0.30 mg/dL)
  • Indirect Bilirubin: 0.4 mg/dL (Normal: 0.00 - 0.90 mg/dL)
  • ALP: 64 U/L (Normal: 41 - 137 U/L)
  • SGOT: 185 U/L (Abnormal, Normal: < 45 U/L)
  • SGPT: 438 U/L (Abnormal, Normal: < 45 U/L)
  • Protein: 6.5 g/dL (Normal: 6.0 - 8.3 g/dL)
  • Albumin: 3.9 g/dL (Normal: 3.2 - 5.0 g/dL)
  • Globulin: 2.6 g/dL (Abnormal, Normal: 1.8 - 2.5 g/dL)
  • Ratio: 1.5 (Normal: 0.6 - 2.0)

Renal Function Tests (RFT):

  • Blood Urea: 46 mg/dL (Abnormal, Normal: 13 - 45 mg/dL)
  • Serum Creatinine: 1.2 mg/dL (Normal: 0.6 - 1.5 mg/dL)

Hematology:

  • Hemoglobin: 11.4 g/dL (Normal Female: 11.5 - 15.5, Male: 12.5 - 17.0 g/dL)
  • RBC Count: 4.7 million cells/cumm (Normal: 4.0 - 6.2 million cells/cumm)
  • WBC Count: 8,900 cells/cumm (Normal: 4,000 - 11,000 cells/cumm)
  • Platelet Count: 3.40 lakhs/cumm (Normal: 1.5 - 4.5 lakhs/cumm)
  • Hematocrit (PCV): 38.9% (Normal: 35 - 50%)
  • MCV: 82.4 fl (Normal: 80 - 100 fl)
  • MCH: 24.2 pg (Abnormal, Normal: 26 - 34 pg)
  • MCHC: 29.3 g/L (Abnormal, Normal: 31 - 35 g/L)

Differential Count:

  • Neutrophils: 79% (Abnormal, Normal: 40 - 70%)
  • Lymphocytes: 15% (Abnormal, Normal: 20 - 40%)
  • Eosinophils: 3% (Normal: 2 - 6%)
  • Monocytes: 3% (Normal: 1 - 6%)
  • Basophils: 0% (Normal: 0 - 1%)

Thyroid Stimulating Hormone (TSH):

  • TSH: 5.87 mIU/mL (No change from Day 1)

CSF:

  • Protein: 290.51 mg/dL (No change from Day 1)
  • Cell Count: 6 cells/cumm (Normal)

Summary of Abnormal Values:

  1. Liver Function:
    • SGOT (AST): Elevated across all days (Day 1: 347.1, Day 3: 444, Day 4: 185)
    • SGPT (ALT): Elevated across all days (Day 1: 446.3, Day 3: 997, Day 4: 438)
    • Globulin: Elevated (Day 1: 3.8, Day 3: 2.6, Day 4: 2.6)
    • Direct Bilirubin: Elevated (Day 4: 0.4 mg/dL)
  2. Renal Function:
    • Blood Urea: Elevated (Day 4: 46 mg/dL)
  3. Hematology:
    • MCH: Low (All days: 24.6 pg, 24.2 pg)
    • MCHC: Low (All days: 29.8 g/L, 29.3 g/L)
    • Neutrophils: Elevated (Day 4: 79%, Day

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