Internship posting



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.

CASE

A 29 year  old male , resident of choutuppal , attender by  occupation in registration office came with the chief complaint of
Tremors since 2 months
Visual disturbances since 2 months
Forgetfulness since 2 months
Difficulty in walking since 2 months
Generalised weakness since 2months


HOPI:

Patient was apparently asymptomatic 2 months  back then he developed fine tremors which were  gradual in onset ,progressive in nature, no aggravating or relieving factors.
Then he developed visual disturbances 2 months back which started as visual hallucinations.(nothing ~rubberband) ,( nothing  ~curry ,rice) illusions(iv set~charger) (bed ~table)(floor ~well).
Memory loss  since 2 months which was gradual in onset , progressive in nature which started initially from forgetting the place where he kept money and searching all around ,later  it progressed to disturbance in daily routine activities ( forgetting daily tablets ). 
Generalised weakness since 2 months which was gradual in onset and progressive in nature.No history of body pains.
Difficulty in walking since 2 months which was progressive in nature.
H/O falls while walking associated with fear of falling while walking. 
No history of buckling. 
No history of difficulty in standing from sitting.
No history of difficulty in wearing and holding chappals.
No history of pain in calf muscles. 
No h/o difficulty in getting up from lying down.
No h/o difficulty in holding pen/buttoning/unbuttoning and combing.
No h/o difficulty in breathing 
No h/o difficulty in lifting the head off the pillow
No h/o difficulty to roll over the bed
No h/o fasciculations/muscle twitchings
No h/o sensory deficit in feeling clothes
No h/o sensory deficit for hot/cold
No h/o tingling and numbness in UL & LL
No h/o band like sensation,low backache,giddiness while washing face ,cotton wool sensation
No h/o urgency/hesitancy/increased frequency or urinary incontinence
No h/o of fever,nausea/ vomiting/diarrhea.
No h/o seizures,trauma,spinal disturbances.
No h/o abnormality in perception of smell,difficulty in eye movements,abnormal sensation of face,difficulty in chewing food,difficulty in closing eyes,drooling of saliva,deviation of angle of mouth,epiphora,loss of taste sensation,deafness,vertigo, difficulty in swallowing,nasal regurgitation, hoarsness of voice,wasting of tongue or fasiculations.
No h/o difficulty in reaching objects.
No h/o incoordination during drinking water
No  h/o of neck stiffness.

PAST HISTORY: 

K/C/O retroviral disease since 2005 on ART.

DRUG HISTORY: 

ART: lamivudine,tenofovir, ritonavir,atazanavir




PERSONAL HISTORY: 

Diet : mixed
Appetite:normal
Sleep: adequate
Bowel and bladder : regular
Alcoholic since 5 years and stopped 2 years back.

FAMILY HISTORY: 

His parents were HIV positive


GENERAL EXAMINATION:

Conscious,moderately built and moderately nourished.
No pallor,icterus,cyanosis,clubbing,
lymphademopathy,edema
No neurocutaneous  markers 
Afebrile
BP:100/60 mmhg
PR: 80 bpm
Afebrile
RR:21 cpm.

CVS:

S1S2 heard , no murmurs.

RESPIRATORY SYSTEM:

Bilateral air entry present , normal vesicular breath sounds

P/A:

Soft , non tender

CNS:

 HMF- patient conscious
            oriented to place/time/person
             Hallucinations and illusions present

MMSE- 18/30
Orientation: Date (0)
                      Day(1)
                      Month(0)
                      Season(1)
                      Year(1)
                    Floor(0) Hospital (1) District(1) state                         (1) country(1)

Registration: Named three objects(3)
                        (Coin,pen,water)
                          Able to repeat it and remember

Recollect:   able to recollect after 15 min(3/3)

Attention and calculation: substract 7 from 100                                                 serially 5 times(0/5)

Language: Naming 2 objects(2/2)
                   Able to repeat a sentence(1/1)
                  Able to follow three stage verbal                               command(2/3)
                 Unable to read(0/1)
                Unable to write a sentence(0/1)
                Unable to copy a design(0/1)

CRANIAL NERVES: intact
 
MOTOR SYSTEM 
                                          Right.           Left

Bulk:    inspection       Normal           Normal
             palpation.       Normal            Normal
                                  
Tone:               UL        Increased.        Increased
                         LL.       Increased.        Increased

Power        :   Deltoid               5/5.              5/5.    
                       supraspinatus   5/5.              5/5
                       Infraspinatus    5/5                5/5 
                       Rhomboids       5/5                5/5
                       Serratus anterior 5/5             5/5 
                       Pectoralis major   5/5             5/5 
                       Lattismus Dorsi      5/5            5/5
                       Biceps                   5/5              5/5 
                       Triceps                    5/5             5/5
                       Brachioradialis        5/5            5/5 
                      ERCL                          5/5             5/5 
                      ECU                             5/5           5/5 
                      ED                             5/5             5/5
                     FCU/FCR                   5/5              5/5
                     Iliopsoas                   5/5             5/5 
                     adductor femoris         5/5           5/5
                    gluteus medius               5/5       5/5    
                    Gluteus maximus           5/5          5/5          
                                 hamstrings        5/5               5/5
                               quadriceps femoris      5/5      5/5                         
                             tibialis anterior.        5/5       5/5         
                                tibialis posterior.         5/5         5/5      
                                      peroneii.            5/5              5/5        
                                      gastronemius.      5/5        5/5       
                                       extensor -
                                     digitorum longus.     5/5           5/5      
                             flexor digitorum longus          5/5          5/5                
                                   Extensor hallucis longus     5/5         5/5

Reflexes.  

   Superficial reflexes
                       Right.           Left
Corneal.            +              +
Conjunctival    +             +
Abdominal.      +               +
Plantar            flexor    flexor  
cremasteric.    +                +

    Deep tendon reflexes 
                     Right.             Left
Biceps.         +++                   +++
Triceps.         ++                   ++
Supinator.     +++            +++
Knee              +++              +++
Ankle.               ++              ++
 









 


SENSORY SYSTEM 
                                    RIGHT.           LEFT
SPINOTHALAMIC 
             crude touch.   N.                   N
                 pain.             N.                   N
            temperature.    N.                   N
#
posterior column:

             fine touch.      N.                   N
             vibration.            Not ellicited
             position              Not ellicited       
    
 cortical sensations:

 2 point discrimination   Not ellicited
tactile localisation.         Not ellicited
Graphesthesia                 Not ellicited            
Stereognosis                   Not ellicited

CEREBELLUM

titubation - absent
ataxia - absent
Nystagmus - absent
Rebound phenomenon - absent
Pendular knee jerk- absent
Disdiadokinesia- absent
Intentional tremor :absent

No signs of meningeal irritation

INVESTIGATIONS:

















Fundoscopy:
Normal

CSF protein: 124mg/dl
Sugar:49mg/dl
Chloride : 118mg/dl
CSF culture: negative


Diagnosis:
HAND( HIV associated neurocognitive disorder) with Hbsag with progressive multifocal leucoencephalopathy(PML).



TREATMENT :
Continue ART
Inj optineuron 1 amp in 100 ml NS IV OD
Inj pantop 40 mg IV  OD
BP / PR monitoring
Tab bactrim DS for 5 days BD
Memantine 15 days BD
Donepazil 15 days BD

Advice at discharge: 
Continue ART
Bactrim DS for 5 days BD
Memantine 15 days BD 
Donepazil 15 days BD






        
    
  



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