Patient Biodata: Complaints
Patient Biodata: Complaints
NAME : xxxxxxx
GENDER : Female
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
1
- Living condition : satisfactory
NEUROLOGICAL STATUS
A) Higher cortical function
I) Olfactory Nerve
Observation: -
- Color perception is normal
- Eye condition is normal
2
IV) Trochlear nerve
V) Trigeminal nerve
b) Sensory function
- Pin-prick test – normal(R=L)
- No abnormal pain sensation(R=L)
3
VII) Vestibulocochlear nerve
Observation: - No hearing problems(R=L)
- No ringing in ears, no tinnitus(R=L)
4
C) Oral automatism
MOTOR SYSTEM
Reflex of tendons
Tone of muscles
RIGHT LEFT
Extensor Flexor Extensor Flexor
Upper Proximal decreased decreased decreased decreased
extremities
Distal decreased decreased decreased decreased
Strength of muscles
5
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
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
6
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
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
7
- Problems in deep sensation
TOPICAL DIAGNOSIS
Lesion of spinal motor and sensory neurons, motor and sensory root and peripheral nerve.
METHOD OF INVESTIGATION
CLINICAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
alcoholism
leprosy
neurosyphilis
refsums disease
dysimmune neuropathies
8
TREATMENT
There is no cure for Charcot Marie tooth syndrome. The disease progresses slowly and it
does not affect lifespan.
2. Moderate activity
3. Occupational therapy
4. Orthopedic devices
5. Surgery
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