PaJR Case Reports: 62M Weakness since 1Month.

25-10-2024

This is an online E Log book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patients problems through series of inputs from available global online community experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

The patient is a 62yr old male who is experiencing weakness since one month. Sometimes he feels pain in the knee joints, elbow joints, neck and back. He is experiencing the pain mainly when he is climbing the steps. He had urine infection during the month of July 2024 followed by fever. He was prescribed medicines by a local Doctor.

He suffered with backache during the time in May 2024, for which he was advised U/S abdomen and X Ray LS- Spine. He was diagnosed with calculus of size 6.4mm in the right Kidney. He was advised some medication and was asked to drink more water. The patient found some relief from the pain.

16-05-2024

Reports of Ultrasound Abdomen

History - Pain abdomen.

Liver - Normal in size(13.5cm) and shows

homogeneous echotexture. No focal or diffuse pathology seen. There is no evidence of intrahepatic biliary dilatation.

CBD and portal vein appear normal.

Gall bladder - Contracted

Pancreas - Normal in size, shape and echopattern.

Spleen - Normal in size(9.2cm) shape and pattern.

Kidney

Right Kidney - 9.0×4.6cm

Left Kidney - 9.2×4.6cm.

Both kidneys are Normal in size, shape and echopattern. Cortico medullary differentiation is maintained.

Calculus of size 6.4mm noted in mid pole calyx. Collecting system appears normal.

Urinary bladder - Well distended. No wall thickening seen. No evidence of calculi/mass.

Prostate - Size 2.9×3.8×3.7(volume:22cc)

Mildly enlarged in size, normal in shape and echotexture.

Other findings: No ascites.

IMPRESSION

Right Renal Calculus. Grade I Prostatomegaly.

Digital Radiographof Lumbosacral Spine.

(AP and Lateral View)

HX . Right sided LBA - Visualised bones show normal Density and alignment.

Curvature of spine maintained.

Minimal marginal Osteophytesseen involvingLumbar Vertebrae.

Visualised Vertebral body heights appear normal.

Visualised Intervertebral disc spaces appear normal

Posterior elements including spinoff and transverse processes appears normal.

Pre and bilateral para vertebral soft tissues appear normal.

IMPRESSION: Lumbar Spondylosis.

07-05-2024

COMPLETE BLOOD COUNT

Haemoglobin - 13.8g/dl

Total Leukocytes count - 6600cells/cumm

Neutrophils - 60%

Lymphocytes - 35%

Eosinophils - 04%

Monocytes - 01%

RBC - 4.12

PCV - 42.6%

MCV - 90.4fl

MCH - 29.1pg

MCHC - 36.8g/dl

Platelets - 2.22Lakhs/cumm

C Reactive Protein Titre- Negative mg/dl

13-05-2024

BLOOD URINE.

COMPLETE BLOOD COUNT

Haemoglobin -14.4g/dl

Total Leukocytes count - 6,700cells/cumm

DIFFERENTIAL COUNT

Neutrophils - 55%

Lymphocytes - 40%

Eosinophils - 04%

Monocytes - 01%

RBC Count - 4.38 millions/cumm

PCV - 40%

MCV - 90.2fl

MCH - 31.6Pg

MCHC - 36.4g/dl

Platelets - 1.88 lakhs/cumm

Random blood sugar - 126mg/dl

Blood Urea - 28mg/dl

Serum Creatinine - 1.0mg/dl

Serum Calcium - 10.4mg/dl

Serum Uric Acid - 3.5mg/dl

C Reactive Protein Titre - Negative mg/dl

COMPLETE URINE ANALYSIS

Colour - Yellow

Specific Gravity - 1.014

PH - 6.5

Glucose - Nil

Albumin - Trace

Bile Salts - Negative

Bile Pigments - Negative

Nitrite - Negative

Urobilinogene - IEU/dl - Normal

Leukocytes- Negative

Ketone Bodies - Negative

Pus cells - 3-5

Epithelial cells - Occassional

RBCs - Nil

Casts - Nil

Crystals - Nil

01-10-2023

HAEMOGLOBIN - 13.9gm/dl

VITAMIN D - 32.80mg/dl

HEART TEST ON 02-12-2022

Interpretation

Comments

Normal LV Systolic function.

No RWMA

Normal sized Cardiac Chambers

M Mode/2D Measurements and Calculations.

IVSO (MM): 1.08cm

LVIDd(MM): 4.19cm

FS(MM): 39.2%

IVSs(MM): 1.47cm

LVIDs(MM):2.55cm

EDV(Tiech)(MM) :78.3ml

LVPWD(MM): 0.963cm

ESV(Tiech)(MM): 23.4ml

LVPWs(MM): 1.13cm

EF(Tiech)(MM): 0.700

EDV(Cubed)(MM) 73.7ml

LV Mass(c)d(MM): 141grams

SV(Tiech)(MM): 54.8ml

SV(Cubed)(MM): 57.1ml

ESV(Cubed)(MM): 16.6ml

EF(Cubed)(MM): 0.775

Ao Root Diameter(MM):2.10cm

LA/AO(MM): 1.84

LA Dimension(MM): 3.85cm

Dappled Measurements and Calculations M

MVE Point : 75.4cm/s

MVA Point : 60.0cm/s

AI Max Vel : 103cm/s

PA acc time : 0.169 sec

Max PG ( AI): 4.21mmhg

03-12-2022

LIPID PROFILE

Serum Status - Clear

Triglycerides - 128

Total Cholesterol - 208

LDL Cholesterol - 134

HDL Cholesterol - 48

VLDL Cholesterol - 26

Total Cholesterol/HDL Cholesterol Ratio

4.3

LDL/HDL Cholesterol Ratio - 2.8

FBS - 95mg/dl

PLBS - 115mg/dl

07-10-2023

COMPLETE BLOOD PICTURE (CBP)

Haemoglobin - 14.3gm/dl

Total RBC - 4.7millions/cumm

Hematocrit - 42.7%

MCV - 91.0fl

MCH - 30.5gm/dl

MCHC - 33.5gm/dl

RDW - 14.0%

Total Leukocytes - 8400cells/cumm

Neutrophils - 71%

Lymphocytes - 23%

Eosinophils - 02%

Monocytes - 04%

Basophils - 00%

ABSOLUTE LEUKOCYTE COUNT

Absolute Neutrophils count - 5964cells/cumm.

Absolute Lymphocytes count - 1932cells/cumm

Absolute Eosinophils count - 168cells/cumm

Absolute Monocytes count - 336cells/cumm

Platelet Count - 242000cells/cumm

Peripheral Smear RBC(P/S) - Nomocytic

Normochromic

WBC (P/S) - Normal in morphology, maturity and distribution

Platelets - Adequate.

REMARKS

No abnormal cells or haemoparasites seen.

MICROALBUMIN URINE SPOT

Urinary micro albumin- 1.32mg/dl

Urine Creatinine - 147.60mg/dl

Micro Albumin urine/Creatinine Ratio

8.94mg/gm

Microalbuminuria - 3.-299

Clinical Albuminuria - >/=300

Uric acid - 6.9mg/dl.

THYROID PROFILE

T3 Total -1.05ng/ml

T4 Total - 9.90

TSH Ultrasensitive - 2.367

Medication for Urine Infection

Tab.Ganspan CV 325mg 2times/day ,5days

Tab.Dolo 650mg 2 times/day , 5 days

Rabeprazole 20mg 2 times/day, 5 days

26-10-2024

PPM 1 - Please share what symptoms did the patient have at that time?

PA - Sir Cyclic fever with paracetamol 650mg and burning while passing urine.

PPM 1 - How many days?

PA - Fever was treated by paracetamol for about 3 days. Local Doctor advised medication for 5 days.

PPM 1 - And after that did he experience any weakness at that time?

PA - No weakness Sir. During May 2024

while taking treatment for backache Vitamin tablets were taken, after that no weakness.

Drinking 3 glasses of water.

27-10-2024

PA - Breakfast, Chapati and Tea.

Drank 2 glasses of water.

PPM 1 - Please mention your hourly activities yesterday.

28-10-2024

PA - The patient drank 3 glasses of water at 8am. Ate pumpkin and sunflower seeds.

PPM 1 - 👍

PA - Breakfast

Patient's Daily Routine

7.30am - Wake up

8 am - Drinking 3 glasses of water.

8.30am - Eat Dry fruits.

9 am - Tea or Coffee

10 am - Watching TV news or checking messages or mails.

10.30am - Breakfast

12.30pm - Drinking 2 glasses of water

1 pm Watching TV

2 - 2.30pm - Lunch

3 pm - Maintenance of Domestic Items

4 - 5.30 pm - Relaxing/ sleeping

6 pm - Drinking 2 glasses of water. Sometimes having snacks.

7 pm - Walking on Terrace for 20min.

8.30 - Light dinner.

9 pm - Watching TV or Domestic work.

10.30pm - Sleeping.

PPM 1 - 👍

At what hourly time points did the patient experience weakness yesterday.

PA - Sir the patient felt weakness after

lunch and sometimes later in the evening.

However the patient will monitor closely and update tomorrow.

PPM 1 - At 2.30pm after lunch how many hours did the patient feel weakness? While doing Domestic items maintenence, was the weakness making the job difficult?

PA - Not exactly Sir.

PPM 1 - So the weakness didn't bother much at that time. Did the patient feel more weakness at 7pm?

PA - Patient Drinking 2 glasses of water.

Lunch, Rice with Bittergourd stew, dal, boiled green moong dal and carrot cucumber curd salad.

Coconut, groundnut, gingely Laddu.

PA - Sir the patient felt weakness at 3.30pm and after a nap of 1hr he felt good.

PPM 1 - 👍

What was the patient's activity before the nap?

PA - Sir the patient felt weakness without any activity. As a retired person he does his domestic work on requirement basis but not everyday.

The patient had a walk on terrace for half an hour. He is okay.

29-10-2024

PA - Patient Drinking 3 glasses of water at 8am. Drinking 300ml warm water with lemon and honey at 8.05am. Dry fruits at 8.30am. Later had coffee.

PPM 1 - 👍

Breakfast dosa with groundnut chutney.

30-10-2024

PA - The patient drinking 2 glasses of water at 8.15am, 300ml warm water with lemon and honey at 8.30am.

Eating pumpkin and sunflower seeds.

Breakfast Dosa with groundnut and tomato chutney.

Lunch Rice with cabbage and potato, boiled Chana and carrot curd raitha.

01-11-2024

PPM 1 - 👍 How is weakness and hrly activities.

PA - Sir today around 4 pm the patient felt weakness.

PPM 1 - What was the patient's activity before and after that hour? How long did the weakness last?

PA - Had lunch at 2.30pm, after one hour the patient felt weakness and then relaxed for one and half hour and experienced relief.

PPM 2 - Could you please send an image of your legs from the top and from the sides of both legs please? Thanks.

02-11-2024

PA - Drinking 300ml warm water with lemon and honey at 8.15am. 2 glasses of water at 8.30am.

Eating pumpkin and sunflower seeds.

Had tea.

Breakfast.

PA - Sir images of legs.

02-11-2024

PPM 2 - Thanks. Did you previously have hair on legs which is now lost? I ask because this could suggest a neurological issue for your pain- if your pain and weakness is very specific in location then perhaps a few causes can be considered. No obvious loss wasting or atrophy though.

PA - Sir I have very less hair on legs and chest from long time.

Sir I felt weakness occasionally, but knee pain and elbow pains are being experienced recently.

PPM 2 - Alright.

03-11-2024

PA- Drinking 3 glasses of water at 8.30am. Had tea. Guava and banana for breakfast.

Lunch.

04-11-2024

PA - Drinking 300ml warm water with lemon and honey at 8 am.

05-11-2024

PA - Sir the patient felt very weak yesterday evening.

The patient's FS - 80

BP - 120/80

3 days back.

PPM 1 - What were the patient's activities at that time?

PA - The patient's weight is 66kgs and height 167cm. The day was normal with routine activities, no strenuous work. Had one sweet made of dry fruits in the evening and was normal after 1hr. He walked on the terrace for 15min.

06-11-2024