Case wise Active learning and discussion-3

Case 3-- Paraparesis

AN 18 YEAR OLD WITH DIFFICULTY IN WALKING AND BILATERAL WEAKNESS OF LOWER LIMBS

We the MBBS final year students have been given these cases on weekly basis to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

• Link to Reference: 

https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1

• Link to my analysis:

https://shivani2401elogbookmedicine.blogspot.com/2020/05/paraparesis-18-year-old-with-difficulty.html?m=0

ACTIVE LEARNING AND CONVERSATIONAL DECISION SUPPORT TO TREATING TEAM OF THIS CASE :

• My active learning discussion:

[5/22, 18:50] MBBS 2016 UG 3: 2) Presented by Dr Hitesh 2014 batch
https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1

[5/22, 18:52] MBBS 2016 UG 3: Sir...in the case...can scabies be stated in the main complaints of the patient according to priority....because it was found on examination...not complained of by the patient

[5/22, 20:36] Post residency PG1: Yes
Logically main complaint is what the patient complains of
So if the patient complains mainly of paraparesis no point focusing much on scabies

[5/22, 20:48] MBBS 2016 UG 3: Ok sir👍

• OTHER DISCUSSIONS:

"[5/23, 8:53 AM] MBBS 2016 student: Sir in this case why can’t there be an inflammatory cause such polymyositis
https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html
[5/23, 8:54 AM]:MBBS 2016 student Why only peripheral neuropathy is diagnosed
[5/23, 9:02 AM] Postresidency PG1: Very good question. 

So the challenge is to distinguish between these two differentials that are essentially two different anatomical locations of the possible pathology. 

What are the clinical signs and symptoms that can distinguish neuropathy from myopathy is the real question?
[5/23, 9:20 AM]MBBS 2016 student: In neuropathy there may or may not be sensory involvement but in myopathy there is no loss of sensation . 
In myopathy proximal muscles are affected first whereas in neuropathy distal muscles are involved and there is early atrophy
[5/23, 9:25 AM] Postresidency PG1: 👍👏👏
[5/23, 9:26 AM] Postresidency PG1: 👍

Now check out these in the two patients and then question the diagnosis
[5/23, 9:28 AM]MBBS 2016 student: Reflexes are present 
No loss of sensation 
Muscle tenderness 
This features go with myopathy more than neuropathy
[5/23, 9:28 AM] MBBS 2016 student: Thank you sir🙂"

In the group:

[5/29, 20:47] MBBS 2016 UG Student 2: https://rhea9895.blogspot.com/2020/05/case-of-18-year-old-male-with.html

[5/29, 20:48] MBBS 2016 UG Student 2: What is the reason for norwegian scabies in this case? And since he tested negative for all.

[5/29, 20:50] Post Residency PG1: What is the difference between ordinary scabies and Norwegian and which one did he have?

[5/29, 20:51] MBBS 2016 UG Student 13: He had Norwegian scabies sir. It's more likely as he didn't feel any itching sensation

[5/29, 20:51] MBBS 2016 UG Student 13: Which is characteristic in Norwegian. 

And it's also more likely to pict in immunosupressed persons

[5/29, 20:51] MBBS 2016 UG Student 13: Which he is, due to his regular alcohol consumption

[5/29, 20:54] Post Residency PG 2: The patient had itching previously but then he got permithrin application done before he has come to our hospital .

May be he scabies got healed partly and he had no itching.

[5/29, 20:59] Post Residency PG1: 👍👏👏 Thanks for participating

[5/29, 20:59] MBBS 2016 UG Student 2: Yeah that could be possible

[5/29, 21:00] MBBS 2016 UG Student 13: Okay Maam.

[5/29, 21:00] Post Residency PG1: Can you share some literature links and quote the relevant portion?

[5/29, 21:00] MBBS 2016 UG Student 2: Okay. So since how long did he have scabies?

[5/29, 21:07] MBBS 2016 UG Student 13: https://www.medicinenet.com/what_is_norwegian_scabies/views.htm.    

"Crusted scabies almost always affects people with a compromised immune system"

"Interestingly, itching maybe absent or minimal in this form of scabies.

[5/29, 21:41] Post Residency PG1: 👍

In the group:

[5/29, 22:09] MBBS 2016 UG 23 Kims: http://durgamahadev118.blogspot.com/2020/05/gm-paraparesis-case-of-23yr-old-elog.html

My questions r in this log book

[5/29, 22:44] MBBS 2016 UG Student 19: 1 : Change of position may be due to pain due to abscess. So frequent change in position may give him relief

[5/29, 22:49] MBBS 2016 UG Student 18: What is the cause for non projectile vomiting .?

[5/29, 22:50] MBBS 2016 UG Student 16: Why vomitings have occured? Are there any signs of Raised ICT? If not so what can be the reason?

[5/29, 22:54] MBBS 2016 UG Student 15: May b

[5/29, 22:54] MBBS 2016 UG Student 15: Due to

[5/29, 22:54] MBBS 2016 UG Student 15: Turberculoma

[5/29, 22:54] MBBS 2016 UG Student 15: Lesions... AST is elevated which might cause vomitings

[5/29, 23:07] MBBS 2016 UG 23 Kims: Cause - https://www.medicalnewstoday.com/articles/325838#causes

[5/29, 23:07] MBBS 2016 UG 23 Kims: https://www.medicalnewstoday.com/articles/325838#causes

[5/29, 23:12] MBBS 2016 UG 23 Kims: No ! There is no raised ict . So no projectile vomitings

[5/29, 23:55] MBBS 2016 UG 24 Kims: Is there a relation between gluteal abscess and tb in this patient ?