59 Years Old Female with ALS

E-LOGS MEDICINE 

Hi, I am Arefin Sadat, a final-year MBBS student. This is an E-Log that depicts the patient-centered approach to learning medicine. This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post. I hope you learn valuable information after giving it a good read.

CASE OF A 59-YEAR-OLD FEMALE WITH ALS

This is a case of a 59-year-old female who is an employee of a company. This de-identified blog was created after taking informed consent from the patient.

CHIEF COMPLAINTS 

1. She lost the strength of both her upper & lower limbs, including her waist & fingers, for 5 months which got severe in the last month.
2. Cannot walk for 1 month
3. Lost her balance for 1 month

History of Presenting Illness

She was reasonably well till June month and had all regular activities.

In the month of June, one day, she slipped twice in the yard & on the bank of the well. She suffered a lot of this leg injuries, and suddenly she was not able to walk and had a disbalance on her left leg, which gradually spread to her left hand. For a few months, she walked with this condition and did her daily activities.

For the last month, she has not been able to walk on both legs. Even she cannot stand properly and doesn’t have the strength and balance in her waist to hold her body for a walk. In her current situation, she can sit in the bed; her supporting hands take her to the toilet and shower. She has intact superficial & deep touch sensation.

She can speak now and swallow all types of food; she can have her food with a spoon slowly.

Her memory is still active, and she can recall all past activities.   

They visited 3 doctors and suggested tests like MRI, NCV, and EMG tests. After that, they confirmed its ALS.

Now she is taking 2 Medicine related to this disease 1) Rilozol 2)  Vitamin E .

Patient's Diet 

-Breakfast: tea, biscuits

-Lunch: rice, vegetables

-Dinner: roti/rice, vegetable

(She is a vegetarian and eats fish/meat once a week)

Personal History  :

Diet - vegetarian

Appetite - Normal

Bowel- Normal and once a day

Bladder movements - Normal

Clinical Images:

Clinical Reports:

Prescriptions : 

MRI Report : 

NCV & EMG Report : 

Blood Test Report : 

CDSS:

[11/21/22, 7:56:59 PM] Patient 59F: Good Evening Doctor. 

[11/21/22, 9:44:34 PM] Arefin Sadat: Greetings!

[11/21/22, 9:45:34 PM] Arefin Sadat: https://dr-arefin.blogspot.com/2022/11/59f-with-als.html

Here is the updated case report with deep tendon reflex videos of the patient: 59F with ALS

[11/21/22, 10:20:12 PM] Patient 59F: New symptom we found today , according to her it's very old , below video FYR

‎[11/21/22, 10:21:35 PM] Patient 59F: ‎<attached: 00000013-VIDEO-2022-11-21-22-21-35.mp4>

[11/21/22, 10:41:48 PM] Dr. Rakesh Biswas sir: Looks like brachial artery pulsations.

[11/22/22, 4:16:03 PM] Patient 59F: is there any medical center to take her for treatment, please suggest

[11/22/22, 4:20:16 PM] Dr. Rakesh Biswas sir: All medical centers will examine her and may offer some treatment but once they too clinically confirm the diagnosis of ALS there isn't much effective treatment medical science has been able to discover till now for this condition. 

Most centers can try to find solutions to support her current activities using what are currently called neurorehab tech. 

Please share her hourly activities here so that we can assess her current requirements

[11/22/22, 4:25:08 PM] Patient 59F: Sir , she dosen't have strength on her waist to Stand or walk, please advise if there is any treatment / surgery  which can help her

[11/22/22, 4:34:03 PM] Dr. Rakesh Biswas sir: As per the data you have shared till now through @8801316197024 (AS) this could be ALS in which case surgery is not available but for any paraplegic one of the neurorehab solutions available in US is "exoskeleton" and other devices. 

You can read more about them here https://link.springer.com/article/10.1007/s00415-022-10971-w

Some of our team members are researching on these technologies. @8801316197024 (AS) may be able to put you in touch with our team member and robotics expert, Abhishek Choudhury who is also there in our PaJR volunteers group

‎[11/23/22, 12:22:13 AM] Dr. Dinesh Datta: ‎<attached: 00000019-PHOTO-2022-11-23-00-22-13.jpg>

[11/23/22, 8:33:02 AM] ‪+977 981‑7599973‬: For this case

- do they use well water for drinking or other household purpose?

- What filter they use for drinking water?

- please share her district and state name.

Well water is associated with sporadic ALS caused by probably fungal infection or inorganic toxins like selenium. Lead toxicity also one possibility due to sindur, so can we know if she is hindu?

What is his husband's age and how is his health?

[11/23/22, 8:33:37 AM] Dr. Rakesh Biswas sir: Share all the references too

‎[11/23/22, 8:34:22 AM] ‪+977 981‑7599973‬: ‎image omitted

[11/23/22, 8:34:25 AM] Dr. Rakesh Biswas sir: 👆@919836213355 Please see if you can answer @9779817599973 's questions

‎[11/23/22, 8:34:56 AM] ‪+977 981‑7599973‬: ‎image omitted

[11/23/22, 8:47:28 AM] Dr. Rakesh Biswas sir: Share clickable links too

[11/23/22, 8:49:03 AM] ‪+977 981‑7599973‬: https://pubmed.ncbi.nlm.nih.gov/16909025/

[11/24/22, 12:11:36 PM] ‪+977 981‑7599973‬: @919836213355 

The importance of questions is, if she consumes water from well, can stop that. If it's in a district where water toxicity with metals are common then we may look into research to find ALS scenario there as sometimes toxicity treatment may help symptoms. If filter at home then better if family members consume water from that and avoid from well if we find possible connection.

[11/24/22, 12:12:25 PM] ‪+977 981‑7599973‬: So whenever possible, you may find answers from patient or their family.

[11/24/22, 2:34:26 PM] Patient 59F: we have RO machine , from there we are Drinking water

[11/24/22, 7:04:07 PM] Dr. Rakesh Biswas sir: Does she use a wheel chair?

[11/24/22, 7:17:47 PM] Patient 59F: No sir

[11/24/22, 7:40:44 PM] Dr. Rakesh Biswas sir: Is she able to walk nowadays?

[11/24/22, 7:45:23 PM] Patient 59F: No she is not able to walk, she need support to walk, once we hold her hand with that she is walking with very slow step

[11/24/22, 7:48:57 PM] Dr. Rakesh Biswas sir: Alright that means she can walk with support. 

How long does she walk daily? 

Is she able to walk from her bed to the bathroom and able to look after herself?

[11/25/22, 10:52:07 PM] ‪+977 981‑7599973‬: Any ayurvedic medication use by the patient now, recently/ recent past?

Please list all if used with duration used for.

They sometimes cause lead toxicity.

[1/13/23, 11:24:57 PM] Arefin Sadat: @919836213355 can you please tell the current condition of the patient? Is there any visible progress?

[1/14/23, 8:03:40 AM] Dr. Rakesh Biswas sir: Please ask them to share their daily energy input (food plates) and outputs (hourly activities).