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Patient Biodata: Complaints

The patient is a 48-year-old female who complains of muscle weakness, difficulty lifting her feet, and decreased sensation in her legs and feet. She has a family history of the same condition in her grandmother. On examination, she has decreased reflexes, muscle tone, and strength in her extremities as well as sensory loss and ataxia in her legs. Based on her progressive neurological symptoms since age 18 and positive family history, she appears to have a hereditary sensory and autonomic neuropathy.

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0% found this document useful (0 votes)
104 views10 pages

Patient Biodata: Complaints

The patient is a 48-year-old female who complains of muscle weakness, difficulty lifting her feet, and decreased sensation in her legs and feet. She has a family history of the same condition in her grandmother. On examination, she has decreased reflexes, muscle tone, and strength in her extremities as well as sensory loss and ataxia in her legs. Based on her progressive neurological symptoms since age 18 and positive family history, she appears to have a hereditary sensory and autonomic neuropathy.

Uploaded by

sharen
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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PATIENT BIODATA

NAME : xxxxxxx

GENDER : Female

AGE : 48 Years Old

OCCUPATION : xxxxxx

COMPLAINTS

She complains of muscle weakness in the hands and legs, ankles and pillow like feeling in legs. She also
has difficulty in lifting up her feet at the ankle and decreased sensation or a loss of feeling in her legs and
feet.

ANAMNESIS MORBI

Patient is a 48 year old female, non-smoking, and no history of alcohol abuse. She started having
muscle weakness of the hands and legs when she was 18 years old. The disease progressively
worsened as she ages , now she has deformation of foot (champagne inverted- bottle) and
atrophy of hands due to motor and sensory nerve damage. She also has loss of decreased
sensation across various parts of body.

ANAMNESIS VITAE

According to patient’s family history, the grandmother had the same sickness.

PATIENT’S CONDITION

 General condition : Normal


 Nutrition : Normal

Past medical history


- Childhood illnesses : yes. The symptoms started when she was 18 years old.
- Surgical : xxxxxx
- Trauma : no
- Allergies : not remembered
- Alcohol : regularly, low quantities
- Smoking : no
- Illicit drugs : no

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- Living condition : satisfactory

NEUROLOGICAL STATUS
A) Higher cortical function

 Patient is conscious and is able to act according to her surroundings.


 No headache
 No nausea
 Absence of vomiting
 Absence of restlessness and confusion
 No complaints of insomnia and sleep disturbances.
 Emotional state is good.
 Intellectual function : normal memory, no signs of impairment
 Speech: normal
 No hallucination and delusion.

B) Cranial nerves examination

I) Olfactory Nerve

Observation: no changes in smell sensation.

II) Optic Nerve

Observation: -
- Color perception is normal
- Eye condition is normal

III) Oculomotor Nerve

Observation: - Absence of ptosis(R=L)


- Normal eye movements towards all directions
- Absence of diplopia(R=L)
- Size of pupils – normal(R=L)
- Pupillary reflex : direct – normal(R=L)
Consensual – normal(R=L)
- Normal ocular convergence(R=L)
- Enopthalmus and exopthalmus – absent(R=L)

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IV) Trochlear nerve

Observation: - When looking forward, no strabismus now detected(R=L)


- Normal movement of the eye when looking down and laterally

V) Trigeminal nerve

Observation: - a) Motor function


- Temporal and masseter muscle is firm and equal when asked to
clench teeth(R=L)
- Mandibular movement is normal
- Corneal reflex – normal(R=L)
- Jaw-jerk reflex – absent
- Lockjaw – absent

b) Sensory function
- Pin-prick test – normal(R=L)
- No abnormal pain sensation(R=L)

VI) Abducens nerve

Observation: - Absence of strabismus(R=L)


- Lateral eye movement is normal(R=L)

VII) Facial nerve

Observation: a) Motor part


- Absent of weakness of the face muscles(R=L)
- Can lift up both eyebrows(R=L)
- Normal jaw movements of closing mouth
- Can smile
- No drooping of corners of mouth(R=L)
- Normal inflation of cheeks(R=L)
b) Parasympathetic part
- No lacrimation(R=L)
c) Sympathetic Part
- No problems of taste

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VII) Vestibulocochlear nerve
Observation: - No hearing problems(R=L)
- No ringing in ears, no tinnitus(R=L)

IX) Glossopharyngeal nerve & X) Vagus nerve

Observation:- Dysphagia is absent


- Dysarthria present (slightly)
- Dysphonia is absent
- No pain in throat and tonsil
- Symmetrical soft palate
XI) Accessory nerve

Observation: - No atrophy and fasciculation of muscle of shoulder(R=L)


- Shoulder strength is normal(R=L)
- Contraction of the sternocleidomastoid and trapezius muscle is normal
both right and left part

XII) Hypoglossal nerve

Observation: - Normal protrusion of the tongue


- No deviation of tongue
- Absence of atrophy of the tongue
- No fasciculation of muscles of the tongue
- No fibrillation of the tongue
- Absence of tremor of tongue

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C) Oral automatism

 Palm chin reflex - absent


 No compulsive laughing or crying.
 Pseudobulbar sign is negative

MOTOR SYSTEM

Reflex of tendons

UPPER EXTREMITIES LOWER EXTREMITIES


Right Left Right Left
Triceps reflex decreased decreased

Biceps reflex decreased decreased

Carpo-radial decreased decreased

Knee jerk reflex decreased decreased

Achille’s tendon decreased decreased

Tone of muscles

RIGHT LEFT
Extensor Flexor Extensor Flexor
Upper Proximal decreased decreased decreased decreased
extremities
Distal decreased decreased decreased decreased

Lower Proximal decreased decreased decreased decreased


extremities
Distal decreased decreased decreased decreased

Strength of muscles
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RIGHT LEFT
Extensor Flexor Extensor Flexor
Upper Proximal 5 5 4 4
extremities Distal 5 5 4 4
Lower Proximal 5 5 4 4
extremities Distal 5 5 4 4

Pathological reflex

 Babinski’s test : negative on both legs


 Rossolimo’s test : positive

COORDINATION SYSTEM
 Rhomberg’s test (with open eyes) : positive
 Rhomber’s test (with close eyes) : positive
 Finger to nose test : normal
 Heel-shin test : normal
 Intention tremor : absent
 Dysmetria : absent
 Dysdiadochokinesia : present
 Gait : sensory gait ataxia
 Lhermitte sign : absent

SENSORY SYSTEM
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I. Superficial sensory system:
- pain and temperature sensation is normal.

-Upper limbs-

RIGHT LEFT
Distal Proximal Distal Proximal
Pin-prick test Normal Normal Normal Normal
Light touch Normal Normal Normal Normal
test
Temperature - - - -
test
-Lower limbs-

RIGHT LEFT
Distal Proximal Distal Proximal
Pin-prick test Normal Normal Normal Normal
Light touch Normal Normal Normal Normal
test
Temperature - - - -
test

II. Deep sensation – decrease in lower leg

 Muscle-tendon
 Patient is able to mention correctly the direction of the touched fingers of
her left hands with closed eyes (normal)
 Patient is unable to mention correctly the direction of the touched toes
of her left feet with closed eyes
 Patient is able to repeat the letters written on her upper but unable to
repeat the letters written on her lower left limbs

 Pelvic functions
Normal

SYNDROMAL DIAGNOSIS
Sensory ataxia
- Positive Rhomberg’s test with closed eyes

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- Problems in deep sensation

TOPICAL DIAGNOSIS
Lesion of spinal motor and sensory neurons, motor and sensory root and peripheral nerve.

METHOD OF INVESTIGATION

 Electrodiagnostic tests ( nerve conduction studies and electromyography)


 Genetic testing
 Muscle / nerve biopsy

CLINICAL DIAGNOSIS

 Charcot Marie Tooth syndrome

DIFFERENTIAL DIAGNOSIS

 alcoholism

 leprosy

 neurosyphilis

 refsums disease

 dysimmune neuropathies

 familial amyloid polyneuropathy

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TREATMENT

There is no cure for Charcot Marie tooth syndrome. The disease progresses slowly and it
does not affect lifespan.

Patient advised to do:


1. Physical therapy

2. Moderate activity

3. Occupational therapy

4. Orthopedic devices

5. Surgery

I.M. Sechenov First Moscow State Medical University


MEDICAL FACULTY
Division for Foreign Students with Instruction Conducted in English
Department of Neurology
NEUROLOGICAL STATUS
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Medical Faculty, English Medium, Group 82

Name: Jolyn Ann Verghese


Supervisor: Dr Anastasia Vladimirnova

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