12-12-2024
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking his signed iformed consent. Here we discuss our patient's 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.
In this case the 46 yr old male is a daily wage labourer and agricultural labourer by occupation (works in his field of 2 acres and other's field also.
Primary schooling at his village ( Thenepally, Gurampar mandal Nalgonda) upto 4th class
Toddy consumption started since childhood (during summer and holidays) Lives with his parents & a younger sister, 2 younger brother.
Then he went to hostel from 5th std to 10th std. As he can avoid walking 5km from home to school (used to go home during sundays and Holidays)
• After 10th standard, worked as daily wage labourer in their farm land (10 Acres to whole Family)
In brick making
He was 18 yrs when he completed his 10th started going to school at late age (~ 7-8 yrs of age)
After working for 1 year,
- got married at 19 years of age in the year 1998 (March) wife (14 yrs of age)
- Went to Another village near Miryalguda (Alia) for daily wage labourer for a few days in a year to from 1998 to 2002
- Didn't have children durin these 4 years
- wife took unknown medication suspecting infertility
- 1st child (male) on 2002 June 13.
- after 1 year, had dispute with inlaws during which he sustained trauma to head (had 3 sutures) no other complaints.
- 2nd child (female) in 2004
Since April 4 2016
- generalized weakness throughout the day.
- No diurnal variation, but feels better while working
- h/o polyuria, polydypsia, polyphagia
- h/o back pain on & off, non radiating
on April 24 2021 at 7pm pt developed sudden onset back ache and shoulder pain dragging type non radiating
after 10 minutes pt developed tingling of Rt thumb followed by all fingers, followed by left thumb and other fingers then entire limbs
Then
stayed at home until 8 pm
Then
went to RMP at thenepally was given antacid injection
Not relieved
Went to gurampally RMP there he was given ORS
Not relieved
Went to Nalgonda govt hospital In Auto (walked on his own until bed)
(while in Auto he felt shock like sensation)
After he was in bed he developed sudden weakness of upper limb followed by lower limb ( at around 1 pm)
Metabolic profile and MRI was done, but diagnosis was not told ( went to by hyd after 2 days )
After spine MRI and metabolic profile was told to be diagnosed as Transverse myelitis
He also felt band like sensation in the trunk at the level of nipple
Lost bowel and bladder sensations
Patient was also diagnosed as type 2 diabetes at this admission and started using glimi m1 po bd
After 6 months
Power has started to improve in UL & bowel sensation
now has parasthesia and myalgia of all 4 limbs.
in 2022 October
pt has had fever and cough with sputum diagnosed and treated for pneumonia during which he had worsening of weakness improved after recovery from pneumonia.
Now came to our hospital after urethral injury and hematuria after changing foleys at home,
Went to urologist and incidentally high blood sugars were detected.
Primary schooling at his village ( Thenepally, Gurampar mandal Nalgonda) upto 4th class
Toddy consumption started since childhood (during summer and holidays) Lives with his parents & a younger sister, 2 younger brother.
Then he went to hostel from 5th std to 10th std. As he can avoid walking 5km from home to school (used to go home during sundays and Holidays)
• After 10th standard, worked as daily wage labourer in their farm land (10 Acres to whole Family)
In brick making
He was 18 yrs when he completed his 10th started going to school at late age (~ 7-8 yrs of age)
After working for 1 year,
- got married at 19 years of age in the year 1998 (March) wife (14 yrs of age)
- Went to Another village near Miryalguda (Alia) for daily wage labourer for a few days in a year to from 1998 to 2002
- Didn't have children durin these 4 years
- wife took unknown medication suspecting infertility
- 1st child (male) on 2002 June 13.
- after 1 year, had dispute with inlaws during which he sustained trauma to head (had 3 sutures) no other complaints.
- 2nd child (female) in 2004
Since April 4 2016
- generalized weakness throughout the day.
- No diurnal variation, but feels better while working
- h/o polyuria, polydypsia, polyphagia
- h/o back pain on & off, non radiating
on April 24 2021 at 7pm pt developed sudden onset back ache and shoulder pain dragging type non radiating
after 10 minutes pt developed tingling of Rt thumb followed by all fingers, followed by left thumb and other fingers then entire limbs
Then
stayed at home until 8 pm
Then
went to RMP at thenepally was given antacid injection
Not relieved
Went to gurampally RMP there he was given ORS
Not relived
Went to Nalgonda govt hospital In Auto (walked on his own until bed)
(while in Auto he felt shock like sensation)
After he was in bed he developed sudden weakness of upper limb followed by lower limb ( at around 1 pm)
Metabolic profile and MRI was done, but diagnosis was not told ( went to by hyd after 2 days )
After spine MRI and metabolic profile was told to be diagnosed as Transverse myelitis
He also felt band like sensation in the trunk at the level of nipple
Lost bowel and bladder sensations
Patient was also diagnosed as type 2 diabetes at this admission and started using glimi m1 po bd
After 6 months
Power has started to improve in UL & bowel sensation
now has parasthesia and myalgia of all 4 limbs.
in 2022 October
pt has had fever and cough with sputum diagnosed and treated for pneumonia during which he had worsening of weakness improved after recovery from pneumonia.
Now came to our hospital after urethral injury and hematuria after changing foleys at home,
Went to urologist and incidentally high blood sugars were detected.
PPM 1 - 70M with mild backache from neck to lower back since 5 years and then suddenly one day in April 2021 he developed severe pain in the neck to back and over 24 hours developed paralysis of both upper and lower limbs along with loss of sensation from chest to lower limbs. Also he had retention of urine for which a urinary catheter was inserted.
On today's examination upper limb biceps 4/5 and triceps 1/5 with marked wasting while lower limbs bilaterally 2/5 (to be reviewed again by @~K Shiva Sai Nagendra). Reflexes absent in all four limbs muscles and planter extensor bilateral. Sensory normal till C5 dermatome followed by variable distal loss as marked in the image
What would be your clinical provisional diagnosis?
PPM 3 - GBS/Syrinx
If biceps 4, then why reflex absent?
PPM 1 -👍
PPM 3 - Pain? Get ASIA scaling done.
PPM 1 - Currently nil.
Sensory part of the reflex arc has the break?
It was quite an acute quadriparesis over24 hrs in April 2021
GBS is LMN peripheral neuropathy
Syrinx is UMN spinal cord
Which one would you pick?
PPM 3 - Acute phase, GBS possible. But injury in past indicated syrinx.
PPM 1 - No history of injury but he did develop a backache two years preceding the illness.
For rehab walk support we are fancying an exoskeleton 👇
PPM 3 -Go 🐌
However, dreaming is must 🤗
PPM 1 - Here's his MRI.
PPM 3 - ADEM🤔
13-12-2024
PPM 1 - Could be a probable etiologic diagnosis although slightly unlikely given that in the history there was no other features of inflammation such as fever etc and well it's just limited to a long segment of the spinal cord and we don't have any evidence of involvement of other areas of the CNS
However regardless of etiology, what would be our impression of the gross pathology visible in the spinal cord here if any?
PPM 3 - Immunodeficiency?
PPM 1 - He did have diabetes a few years back and has the typical type 2 diabetes metabolic syn phenotype but then it's difficult to explain his spinal cord lesion with that.
👆 What's your specialist viewpoint about exoskeletons and their future promise in not just alleviating spinal cord mobility miseries but also as a future wearable mobile live in device?
PPM 3 - Yes, very powerful. However prohibitive cost holds us from prescribing.
In fact I see IPR as the biggest demon of the Century (perhaps 2 centuries).
PPM 1 - 👍
But that website is a made in India exoskeleton retail site apparently from Karnataka!
How costly can it be?
More importantly how efficacious is it?
Can also spur innovative workarounds.
PPM 3 - 👍
I didn't know a Made in India item. Abroad it was ₹20 Crores (Or Lacs, please excuse maths of a poor doctor). IIT Delhi was designing it's precursor in year 2000.
PMR is indeed innovative with our innovative Occupational Therapist in the team😌.
PPM 1 - Who's that?
PPM 1 - Exactly even I wasn't. One our PGs @PPM4 searching solutions for this patient's mobility during our bedside point of care learning made us aware of it's India presence and while we asked the patient's son to call the dealer and check the price would be nice if anyone here may be interested to find out and share.
PPM 3 - Not now with me, but any occupational therapist in your team will fulfill the dreams of your patients at your hospital.
PPM 1 - There are none currently!
Is it the same person who made a wheelchair for our neighbour's paralysed dog?
PPM 3 - He is a P&O and can be linked up.
Occupational Therapist shall be available in all Medical Colleges as per NMC norms.
PPM 1 - 👍
Sensory system examination.
Motor system.
Motor system examination continued.
PPM 1 - @PPM5 please share if the make in India exoskeleton guys got in touch with you yesterday. If not would anyone else here @PA who has gone through the case report in the description box want to call up the people here 👇
And ask them the price and an appointment to provide a free trial which can be vetted by our Physiatrist Dr. PPM6 and if he's satisfied we can even try to mobilize resources to fund it.
PA - I have spoken to them and the price is 1.5 cr.
PPM 6 - 🙏
PA - 
PPM 1 - Thanks
Can they give us a free trial for Dr @PPM6 to judge it's efficacy following which we can try to find sponsors.
PA - Yes. They can connect over zoom next week.
PPM 1 - That's great. Let's fix a time for the trial in consultation with @PA2 and
let's update his case report with the above conversations and other data shared about the device so that we can share all these in the case report for potential sponsors.
EMR SUMMARY
Age/Gender : 46 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 07/12/2024 03:11 PM
Diagnosis
UNCONTROLLED TYPE 2 DM
SEPTIC SHOCK SECONDARY TO UROSEPSIS (RESOLVED) URETHRAL INJURY
K/C/O TRANSVERSE MYELITIS SINCE 3 YRS
Case History and Clinical Findings C/O POLYDYPSIA SINCE 2 MONTHS C/O POLYPHAGIA SINCE 2 MONTHS C/O FEVER SINCE TODAY MORNING
HOPI-PT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS AGO THEN HE DVELOPED POLYDYPSIA AND POLYPHAGIA. C/O FEVER SINCE TODAY MORNING, HIGH
GRADE, CONTINUOUS
H/O COLD SINCE 4 DAYS NO H/O COUGH
H/O 1 EPISODE OF VOMITING TODAY EARLY MORNING AT 3 AM, FOOD AS CONTENT, WATERY, NON BILIOUS, NON PROJECTILE
H/O NAUSEA PRESENT
NO H/O PAIN ABDOMEN, LOOSE STOOLS
H/O HEMATURIA AFTER CHANGING FOLEYS 2 DAYS AGO PAST HISTORY-
K/C/O TRANSVERSE MYELITIS SINCE 3 YEARS, ON PALLIATIVE CARE K/C/O TYPE 2 DM SINCE 3 YEARS ON T. GLIMI M1
N/K/C/O HTN, CVA, CAD, SEIZURES, TUBERCULOSIS, ASTHMA
GENERAL EXAMINATION :
PATIENT IS C/C/C
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY, EDEMA BP: 80/70 MMHG
PR: 114 BPM
RR: 24 CPM
SPO2: 96%
SYSTEMIC EXAMINATION :
CVS: S1S2 +
RS: BLAE + NVBS HEARD P/A: SOFT NON TENDER CNS:
HIGHER MENTAL FUNCTIONS NORMAL SENSORY SYSTEM
PAIN ,FINE TOUCH SENSATION ; LOST FROM C7 DERMATOME CRUDE TOUCH LOST FROM T1
VIBRATION: IMPAIRED (4 SEC) IN SHOULDER, ELBOW,RADIAL STYLOID LOST IN ILIAC CREST, TIBIAL TUBEROSITY, MEDIAL MALLEOLUS JOINT POSITION IMPAIRED
MOTOR SYSTEM
TONE DECREASED IN ALL 4 LIMBS POWER:
DECREASED (0) FROM C7 NERVE ROOT REFLEXES:
AREFLEXIA EXCEPT PLANTARS ,EXTENSOR RESPONSE
Investigation
Name Value Range
COMPLETE URINE EXAMINATION (CUE) 07-12-2024 04:03:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR +++BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 4-8
EPITHELIAL CELLS 3-4
RED BLOOD CELLS 5- 6
CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS Absent
OTHERS Nil
HBsAg-RAPID 07-12-2024 04:03:PM NegativeAnti HCV Antibodies - RAPID 07-12-2024 04:03:PM
Non Reactive
BLOOD UREA 07-12-2024 04:05:PM 71 mg/dl 42-12 mg/dlSERUM CREATININE 07-12-2024
04:05:PM 1.6 mg/dl 1.3-0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 07-12-2024 04:05:PMSODIUM 125 mmol/L 145-136
mmol/L
POTASSIUM 4.6 mmol/L 5.1-3.5 mmol/LCHLORIDE 88 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 07-12-2024 04:05:PM
Total Bilurubin 1.37 mg/dl 1-0 mg/dl
Direct Bilurubin
0.25 mg/dl 0.2-0.0 mg/dl
SGOT(AST) 20 IU/L 35-0 IU/L
SGPT(ALT) 26 IU/L 45-0 IU/L
ALKALINE PHOSPHATASE 152 IU/L 128-53 IU/L
TOTAL PROTEINS 6.2 gm/dl 8.3-6.4 gm/dl
ALBUMIN 3.56 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.35
ABG 07-12-2024 04:54:PM
PH 7.39PCO2 25.9PO2 106HCO3 15.5St.HCO3 18.2BEB -7.7BEecf - 8.4TCO2 31.9O2 Sat 98.4O2 Count 15.0RFT 07-12-2024 11:38:PM
UREA 49 mg/dl 42-12
mg/dl
CREATININE 1.3 mg/dl 1.3-0.9 mg/dl
URIC ACID 6.0 mmol/L 7.2-3.5 mmol/L
CALCIUM 9.8
mg/dl 10.2-8.6 mg/dl
PHOSPHOROUS 2.7 mg/dl 4.5-2.5 mg/dl
SODIUM 132 mmol/L 145-136
mmol/L
POTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 101 mmol/L 98-107 mmol/L
COMPLETE BLOOD PICTURE (CBP) 07-12-2024 11:38:PM
HAEMOGLOBIN 11.4 gm/dl 17.0-13.0
gm/dl
TOTAL COUNT 13100 cells/cumm 10000-4000 cells/cumm
NEUTROPHILS 75 % 80-40
%LYMPHOCYTES 11 % 40-20 %EOSINOPHILS 05 % 6-1 %MONOCYTES 09 % 10-2
%BASOPHILS 00 % 2-0 %PLATELET COUNT 2.17SMEAR Normocytic normochromic with leukocytosis
RFT 08-12-2024 10:41:PMUREA 30 mg/dl 42-12 mg/dlCREATININE 1.2 mg/dl 1.3-0.9
mg/dlURIC ACID 5.4 mmol/L 7.2-3.5 mmol/LCALCIUM 9.6 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.5
mg/dl 4.5-2.5 mg/dlSODIUM 134 mmol/L 145-136 mmol/LPOTASSIUM 3.6 mmol/L. 5.1-3.5
mmol/L.CHLORIDE 98 mmol/L 98-107 mmol/L USG ABDOMEN AND PELVIS DONE ON 9/12/24 IMPRESSION:
GRADE I FATTY LIVER
RIGHT RENAL CORTICAL CYST
Treatment Given(Enter only Generic Name)
INJ. IV FLUIDS NS@ 100 ML/HR INJ. TRANEXA 500 MG IV/SOS INJ. MONOCEF 1 GM IV/BD
INJ CLINDAMYCIN 600MG TID
INJ NORAD 8 MG IN 50 ML NS @ 5ML /HR TO MAINTAIN MAP >65 MMHG INJ. HAI S/C TID ACC TO GRBS
INJ.NPH SC BD ACC TO GRBS INJ.PAN 40 MG IV/OD
INJ. ZOFER4 MG IV/SOS
INJ. NEOMOL I GM IV/SOS IF TEMP >101 F
T. PCM 650 MG PO/TID Advice at Discharge 1.INJ.HAI SC TID
10-12-10 UNITS
2. INJ NPH SC BD
8 8 UNITS
3. TAB.PCM 650 MG PO/TID X 5 DAYS
4. TAB.ZOFER 4 MG PO/BD X 5 DAYS
5. TAB.PAN 40 MG PO/OD X 5 DAYS
6. TAB PREGABA NT PO/HS X 7 DAYS
7. SYP CREMAFFIN 15 ML PO/BD X 5 DAYS
Follow Up
REVIEW TO GM OPD AFTER 2 WEEKS OR SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date:13/12/24 Ward:AMC Unit:GM I
17-12-2024
PA - Any Update doctor?
PPM 1 - Alright I just saw this video!
I guess that's pretty much well explained in terms of the mobility promise and all we need to do is ask them how our patient can get a free trial from them to understand it's utility. @Administrator can you liase with these business people and @PPM2 can also guide you if required?
PPM 6 - In Mumbai?
PPM 1 - On zoom from your Mumbai perch.
PPM 6 - 👍
PPM 1 - This is their portfolio👇
PA 2 -
"Good morning, sir/madam. I'm interested in undergoing treatment but I'm concerned about the cost. Unfortunately, the current price is beyond my budget. Could you please let me know if there are any more affordable treatment options available?"
PPM 1 - We are trying our best so that you don't have to pay anything.
It's a slow process and we may fail but we can give it our best shot.
PA 2 - "Thank you so much for your efforts to make the treatment more affordable for me. I really appreciate your willingness to help and your sincerity about the process. Please keep me updated on any progress, and thank you again for your kindness and support.🙏.
PPM 1 - 👍
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