Draft 1@AJND
Proposal:
To discuss and thus showcase the various novel learning opportunities from each individual patient (with ultimate outcome as neurodegeneration) PaJR groups and how those were translated into learning outcomes (and if not why not)
To demonstrate how our learning outcomes from each patient impacted the patient outcomes (or otherwise with reason)
To propose a modification to the current defination of "neurodegeneration" which currently takes into account only the idiopathic or senile ones (eg. Alzheimer's disease) and not the ones secondary to any know cause (eg. In one of our cases it is secondary to electrocution)
Step 1:
Collate each individual patient PaJR learning events in their case report CDSS
Step 2:
Understand how each of their conversational learning opportunities were translated to learning outcomes and also if not then why not
Step 3:
Understand how these learning outcomes were translated to patient outcomes for each of those PaJR patients
Step 4:
Write up the discussion around the strengths, weaknesses, opportunities and threats (SWOT analysis) for this approach
........
FAQs 2:
Potential author : Ohk sir but we do have only few continued follow up , but sure will look into it sir
Rakesh Biswas: That is one of the discussion points.
Why did we have few on our follow up?
What are the possible barriers and solutions to improve PaJR informational continuity?
We may divide it into agent (patient) factors and host (PaJR advocate) factors.
.........
But more importantly we need to demonstrate the link between our learning outcomes in the PaJR cases (also with the daily informational continuity) and their illness outcomes.
Are we positively able to influence their illness outcomes through our PaJR efforts? If not what are the barriers? If yes what is the evidence for that?
You can find Aashita presenting the pivot case in the video link below that finally got published in AJND here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9301093/
..........
Can you share their PaJR group discussions and follow up?
This current AJND write up that we are hoping to submit by the current deadline of February 28 focuses on our learning ecosystem that have been published in the past (UDHC, CBBLE) and particularly focuses on PaJR as an additional tool so that is what we are hoping to showcase with our PaJR followed up neurodegenerative cases.
Active cases on neurodegenerative disease:
Case 1:
https://rishikakolotimedlog.blogspot.com/2022/09/51-year-old-male-with-swelling-and-loss.html?m=1
https://96sanjanapalakodeti.blogspot.com/2022/09/51m.html
[Group name: 51M Mb133 FOOT DROP PAJR]
Case 2:Sister:
https://dr-arefin.blogspot.com/2023/04/53f-with-uncontrolled-hand-movements.html
Brother:
https://dr-arefin.blogspot.com/2023/04/47m-with-uncontrolled-hand-movements.html
[Group name: 53F Huntington JP7 PaJR]
Case 3: http://munukutlasaimythili.blogspot.com/2022/09/a-case-of-50-year-old-man.html
[Group name: Pending [Rishika Koloti]
Case 4: https://dr-arefin.blogspot.com/2022/11/e-logs-medicine-hi-i-am-arefin-sadat.html
[Group name: 39F myelopathy CB25 PaJR]
Case 5: https://dr-arefin.blogspot.com/2022/11/59f-with-als.html
[Group name: 59F with ALS]
Case 6: https://dr-arefin.blogspot.com/2023/03/37m-snake-bite.html
[Group name: 37M Spinal cord UMN paralysis and UMN bladder problems post snake bite since 2015 PaJR TELANGANA]
Model paper:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9301093/
Potential titles:
Patient's journey record PaJR and other medical cognition tools in optimizing clinical complexity of Neurodegenerative disorders
or
Clinical complexity of neurodegenerative disorders and it's optimization through the "Patient's journey record" PaJR and other "medical cognition" tools
..............
Current title : Optimizing clinical complexity in neurodegenerative disorders using medical cognition tools"
Abstract:
We illustrate conversational learning through our udhc global and local CBBLE groups around neurodegenerative disorder patients and topics as well as insights from their informational continuity through PaJR groups
We begin with a few Huntington's chorea patients family who approached us through our PaJR groups and finally traveled 2000 kms to meet us in our hospital where focused genomic studies were done that came positive for Huntington's following which our PaJR team tried to get in touch with an ongoing international clinical drug trial to see if they could register our patients.
We further share our workflow around multiple neurodegenerative disorder patients to demonstrate how PaJR driven informational continuity has the potential to not just improve health professionals learning outcomes but also real patient outcomes
ABSTRACT (Previous)
Neurodegenerative diseases are a group of conditions characterized by progressive and irreversible damage to the structure and function of the central nervous system. This paper aims to examine the complexity of clinical management of neurodegenerative diseases focusing on the challenges posed by the gradual and progressive nature of the diseases. It highlights the importance of early diagnosis, as well as the need for comprehensive and individualized care plans. The paper further explores the various symptoms associated with neurodegenerative diseases and the difficulty of obtaining accurate diagnoses, especially in the early stages of the disease. It will also cover the importance of interdisciplinary collaboration, the need for personalized treatments, and the implications of emerging technologies for clinical practice. The findings of this paper will provide an important insight into the complexity of managing neurodegenerative diseases, which will aid in the development of strategies to improve patient care.
............
The points/headings that I wanted to include under each case discussion:
1. The challenges faced while diagnosing it
2. Challenges faced while coming up with treatment plan
3. Challenges faced while communicating the nature of the disease with the patient/family
4. What we tried to do to support them (here PaJR and CBBLE groups come in)
_________________________ ______ ______
Abstract:
We illustrate conversational learning through our udhc global and local CBBLE groups around neurodegenerative disorder patients and topics as well as insights from their informational continuity through PaJR groups
We begin with a few Huntington's chorea patients family who approached us through our PaJR groups and finally traveled 2000 kms to meet us in our hospital where focused genomic studies were done that came positive for Huntington's following which our PaJR team tried to get in touch with an ongoing international clinical drug trial to see if they could register our patients.
We further share our workflow around multiple neurodegenerative disorder patients to demonstrate how PaJR driven informational continuity has the potential to not just improve health professionals learning outcomes but also real patient outcomes
Keywords: neurodegenerative disorder, case-based blended learning ecosystem, Huntington disease.
Introduction:
Case 1: (https://rishikakolotimedlog.blogspot.com/2022/09/51-year-old-male-with-swelling-and-loss.html?m=1
https://96sanjanapalakodeti.blogspot.com/2022/09/51m.html )
[ Note : CDSS pending - rishika koloti ]
A 51-year old male, farmer by occupation, presented with swelling, foot drop and loss of sensation.
At the age of 25, while playing football, his left foot went into a ditch aaccidentally, which lead to diffuse swelling in his left foot up to the ankle joint. The swelling, lasted for one week, was associated with pain and was not associated with fever, change of colour of the overlying skin or loss of body weight.
The pain associated with the swelling was continuous, localised to the left foot below the level of the ankle joint. The patient was unable to walk, and after taking medication for 1 week the swelling and pain resolved. At the age of 48(3 years ago), while going for a morning walk, the patient accidentally placed the same foot into a ditch and it got twisted. Immediately after, the patient experienced swelling in the left foot, predominantly in the lateral aspect of the dorsum of the foot. The swelling was associated with Pain and not associated with any change in body weight, fever or change in colour of the overlying skin.
X-Ray of the left foot depicted a crack on the lateral aspect of the plantar of the foot. The patient was advised to undergo surgery, but he didn't and thus continued taking prescribed medication for the next 9 months. The patient could walk with a limp but the swelling did not completely subside. A week later, the patient experienced a tingling sensation in the little toe which progressed medially towards the great toe and the patient was unable to flex the great toe towards the dorsum. Later the patient could not flex the foot towards the dorsum. The patient complains that while wearing his slippers, the slippers keep coming off his feet. At 51,(11 months ago), the patient developed an ulcer in the lateral aspect of the plantar of the left foot. The patient did not initially notice the ulcer as there was a loss of sensation present at the time. When the patient first noticed the ulcer, it was 1-2 cm in size, on visiting the doctor, the patient was given cadexomer iodine ointment - that did not provide any relief, later in addition to the ointment, the patient was given oral medications, which have been effective in reducing the size of the ulcer though the ulcer is still present. On CNS examination the patient was conscious ,coherent,oriented to time place and person. Cranial nerve examination findings was normal. Sensory nervous system finding was absence of pain and fine touch in left foot upto the ankle joint and right lower limb sensations was normal.
Motor response of Triceps, Biceps, Brachioradial, Knee joint, Ankle joint was present.
MR findings are suggestive of Lumbar spondylosis seen as carly osteophytic changes, disc dessication and disc bulge.
Mild diffuse annular and postero-lateral bulge of L3-4 disc indenting ventral thecal sac without neural compression.
Diffuse annular and broad based left paracentral herniation of L4-5 disc indenting ventral thecal sac and causing compressions of traversing L5 nerve roots in the lateral recess.
Diffuse annular and postero-lateral bulge of L5-S1 disc indenting ventral thecal sac causing compression bilateral intervertebral neural foramina with mild impingement of exiting nerve roots.
SCREENING OF WHOLE SPINE shows early cervical spondylosis seen as marginal osteophytes, disc dessication and bulges. Small posterior disc bulges noted at C4-5, C5-6 and C6-7 level indenting yentral thecal sac.
Dorsal spine appear grossly normal.
MRI OF LUMBOSACRAL SPINE shows straightening of lumbar spinal curvature withnormal alignment of vertebral bodies.
HRUS EXAMINATION OF LEFT LEG
INDICATION: Footdrop.
* FINDINGS:
* There is long segment focal fusiform enlargement of distal sciatic nerve just proximal to bifurigation in popliteal fossa , measuring 10 mm in maximun diamter.
* The enlargement is seen extending into common peroneal nerve for about a length of 6 em and also involving proximal few 2 ems of tibial nerve.
* The enlarged nerve shows hypoechoie echotexture.
The entire expanded nerve extends for about a length of 10cms
Findings are s/o ?Nerve sheath tumor
MRI- LEFT ANKLE
FINDINGS:
Long segment fusiform swelling of tibial nerve with cystic spaces involving the
nerve in distal one third of leg, tarsal tunnel and proximal part of hind foot with
a maximum thickness of 12mm.
D/D's: Intraneural Ganglion of the tibial nerve, Hamartoma of tibial nerve, Nerve sheath tumor of tibial nerve (Less likely).
Similar lesion seen involving the long segment of common peroneal nerve at the
level of knee joint.
Fatty atrophy of extensor compartment muscle of leg in mid & distal one third of
leg - Suggestive of enervation edema.
Suggestive of foot drop.
Treatment :Gabapentin 100 mg thrice daily and Meaxon afternoon.
Case 2:
Sister
Case report:: https://dr-arefin.blogspot.com/2023/04/53f-with-uncontrolled-hand-movements.html
A 53 years old woman, who works as a teacher complains of uncontrolled movements in fingers and toes since 7 years.
Patient was apparently asymptomatic 7 years back. She then developed slight movements in her fingers and toes that were not under her control. These movements lasted for 10-15 minutes and occurred 2-3 times in an hour. The frequency has now increased. There is no associated weakness. These tremors are of low amplitude and high frequency. They are episodic in nature and also present during sleep. Occur and resolve spontaneously. No triggers.
Aggravated on stretching arms. No relieving factors.
The patient also complains of her hands and feet getting cold and that she suddenly starts sweating a lot.
Over the last 5-7 years, she had fallen down at the bus stop 3 times (while climbing the bus) and 2 times while walking due to loss of balance. She did not lose consciousness and was able to get back up in 1-2 mins by herself. There was no associated injury.
Since 2-3 years, she started developing memory issues. She is unable to recall the person whom she met 2-3 days back. She still remembers her childhood memories. She is now unable to form Hindi and English sentences (she used to be fluent in Hindi and English before this.) Her writing speed and handwriting has also deteriorated.
These complaints have not affected her personal and professional life.
Her maternal grandmother, mother, Brother, and 2 aunties(mothers sister) suffered from similar symptoms(fingers and toes shaking).
She was diagnosed with huntington disease.
…………………………………………
Brother:
Case report: https://dr-arefin.blogspot.com/2023/04/47m-with-uncontrolled-hand-movements.html
A 47 year old male,with the history of rectal hemorrhoids for 7 years, came with the complain of uncontrolled movements in fingers and toes since 3-4 years, Inability to talk properly since 3 years, Difficulty in swallowing since 2 years, Urinary incontinenc. These movements used to occur 1-2 times a day in the beginning, now increased to 5-6 times a day. The severity and frequency seem to be increasing day by day. Movements were also present in his sleep. There is no weakness or loss of grip when these movements occur. No triggers, no relieving factors. The movements in his fingers were clearly seen when he was walking. Complains of water leaking out of his nose while drinking.
Alcohol - drinks occasionally, Smoking - 1-2 cigarettes/day
FAMILY HISTORY:
Link to sister's blog: https://96sanjanapalakodeti.blogspot.com/2022/09/53f-with-uncontrolled-hand-movements.html
On examination: Tremors - High amplitude, low frequency; No triggers; No aggravating/relieving factors
Slurring of speech observed
Cerebellar signs
Titubation - Not observed
Gait/stance ataxia - Not observed
Nystagmus - Not observed
Dysarthria - Not observed
Hypotonia - Not observed
Rebound phenomenon - Positive
Intention tremor -
Pendular knee jerk -
Tandem walking - Not observed
Finger nose test - Slight hypometria observed
Drawing a circle - Normal
Knee heel test - The patient was unable to do it
Dysdiadokokinesia - Not observed
Patient was instructed to say 'ma', 'ba', 'pa', 'ta', 'da', 'la', 'ka', 'gha' and was able to repeat it without difficulty
Weak raising of the palate when instructed to say 'AAA'
MMSE - 26 (language barrier to be considered)
DISCUSSION:
There is a disagreement on whether his movements are choreatic or athetoid.
Family history shows an aunt whose genetic testing was done that revealed possible Huntingtons.
We consulted with a geneticist Dr. A. H. who suggested that we test for HD, SCA types 1, 3, and 12. There was also a discussion on how there was a possibility of 2 genetic disorders running in the family, though it is rarely seen. 2ml EDTA blood samples of both the patients (brother and sister) were sent for testing.
It was decided that based on the results, the rest of the family members could be counseled. It was stated that if a defect was seen in SCA1 or SCA12, preventive measures can be taken to decrease the severity of the symptoms in future generations (?).
CONVERSATIONAL LEARNING:
Dr Sanjana:
We've done these tests till now
Tremors - High amplitude, low frequency; No triggers; No aggravating/relieving factors
Slurring of speech observed
Cerebellar signs
Titubation - Not observed
Gait/stance ataxia - Not observed
Nystagmus - Not observed
Dysarthria - Not observed
Hypotonia - Not observed
Rebound phenomenon - Positive
Intention tremor -
Pendular knee jerk -
Tandem walking - Not observed
Finger nose test - Slight hypometria observed
Drawing a circle - Normal
Knee heel test - The patient was unable to do it
Dysdiadokokinesia - Not observed
Patient was instructed to say 'ma', 'ba', 'pa', 'ta', 'da', 'la', 'ka', 'gha' and was able to repeat it without difficulty
Weak raising of the palate when instructed to say 'AAA'
MMSE - 26 (language barrier to be considered)
Dr. Rakesh Biswas: Well done 👏 By the nature of the slurring can you tell if it's spastic dysarthria or cerebellar speech.
Dr. Sanjana: I personally think it's cerebellar sir (scanning speech)
@Amili will be able to tell us about that more accurately as she primarily communicated with him.
Cerebellar speech:
Spastic dysarthria:
@Amili which one do you think his speech resembled the most?
Dr. Amili: Yes ma'am, the patient has speech resembling that of the cerebellar speech video link. Although I would also like to mention that he did not speak as slowly as that shown in the video. There were times where he struggled to pronounce some words and a slight bit of slurring was observed.
Dr. Rakesh Biswas: @Amili What anatomical areas do you think are currently involved in the 47M patient under discussion based on the physiological parameters you have with you now as a result of the detailed examination findings shared above
Dr. Souraja: Sir, we have specific nuclei in the basal ganglia, the caudate. The degeneration of this nucleus will cause huntington.. Also the levels of GABA decreases.
Since GABA is an inhibitory neurotransmitter, the excitatory impulse overrules and person has chorea and involuntary movements in eye and speech slurring
Dr. Amili: Sir, after reviewing the list of physiological parameters that are currently present, I have come to the following observations:-
1.)Due to presence of tremors, the spinomotor system can be involved
2.)The patient has complained about the inability of retention of urine for long periods of time, thereby indicating slight disturbance in the centre responsible for micturation i.e. the Pontine micturition center(PMC), which is located in the medial dorsal pons.
3.) Cerebellar speech is observed... Due to the slurring although there is no slowness of speech observed, which indicates that the extrapyramidal tracts are not involved.
4.)There is also unsteadiness in his gait that has been observed, which is accompanied with swaying from side to side occasionally and his inability to negotiate narrow pathways, which further proves that the cerebellum is being involved
.
Dr. Amili: So, based on his gait (which I would describe as Trunkal Ataxia as it is quite staggered), I can say that the archicerebellum involvement is there, but I am guessing there is more involvement of the neocerebellum seen due to the following observations:-
1.) The patient does seem to have Dysmetria because he seemed to have difficulty in performing the finger nose test
2.) Dysarthria, due to his slurred speech.
Dr. Sanjana: Patient also mentions difficultly in getting up from chair and out of bed, so truncal ataxia is very probable
Dr. Rakesh Biswas: So now if you check out the other case report of Huntington's similar to our current patient you may realize that Huntington's may involve other locations in the brain too. @Souraja @Amili What is the tone and reflexes that you examined in this patient? Can a patient having ataxia walk tandem as we demonstrated outside Dhanwantari yesterday? @Sanjana Palakodeti @Souraja We need the deidentified videos of this patient's reflexes as well as gait, including tandem along with the dysmetria. Check out normal and abnormal CNS examination videos in YouTube and you will know how to take yours and upload it in a similar manner and then share the links here as well as in the 47M case report
Dr. Amili: Sir, from what me and @Sanjana Palakodeti have examined so far yesterday, we have found that the muscle tone in both the upper and lower limbs is normal. We have also examined the jaw reflex as well as the knee jerk reflex. The knee jerk reflex seemed to be normal although we both noted that it was slightly exaggerated. So it has been noted to retest that. There is no jaw reflex that was noticed so we thought of retesting that too.
Sir, based on this video I don't think that a patient having ataxia can walk tandem to as was demonstrated outside Dhanwantari yesterday
Dr. Rakesh Biswas: So what is our patient's gait like? How do we classify it? Can we call it spastic gait? Check that out too and would be great if someone can share the gait video of our patient
Dr. Amili:
https://stanfordmedicine25.stanford.edu/the25/gait.html
Sir for rewatching the patient video which was posted here, I don't think we can call this spastic gait cuz there is no "scissoring" that has been observed so far... The key pointers that I have noticed so far after being with this patient are:-
1) he seems to have difficulty when he is asked to walk in a straight line. (Can't seem to cross his legs)
2) his fingers sometimes flex and extend while he is walking
3) The patient did also mention his toes also contracting at times when he is walking although that has not been observed in real life nor on video so far
4) also it is staggered
Case 3: ( http://munukutlasaimythili.blogspot.com/2022/09/a-case-of-50-year-old-man.html )
A 61 year old male, daily wage labourer in construction work, presented with
CHIEF COMPLAINTS
Dry cough since 10 days
Dragging pain towards the finger tips since 10 days
Lower back pain since 10 days
Shortness of breath Grade 2 -grade 3
Chest pain near heart since 10 days
Patient was apparently asymptomatic 3 years back. Then he noticed involuntary movements of upper right limb at rest and decreased on movement.
2 years ago his wife passed away because of which he became reclusive and increased intake of alcohol. 1 year back he noticed showing of moments and decrease in his pitch of voice.
He has used medication but stopped using after 5 months due to lack of improvement of symptoms.
Since 20 days back he has trouble recollecting and takes at least 30-40 minutes if he wants to do something like bringing a article from home. Then 10 days back he experienced dry cough.
Lower back pain on both sides draging type radiating towards the coccyx. Pain in upper right arm radiating towards the finger tips which is dragging in nature. Both of which were relieved on medication and rest.
Chest pain more of a burning sensation since 10 days.
Shortness of breath Grade 2 -3
Not relieved on rest
No association with vomiting or headaches
His appetite is decreased and after demise of wife he became addicted with cigarette and alcohol.
GENERAL EXAMINATION
Thin built and malnourished
Vitals
Temperature : Afebrile
Pulse: 81
BP:110/80 mm/ hg
RR :18
SPO2 : 97%
Pallor : present
Icterus present
Clubbing absent
Cyanosis absent
Lymphadenopathy absent
Pedal edema absent
JVP RAISED
SYSTEMIC EXAMINATION
CVS
Apex beat 6 th intercoastal space
No thrills
S1 S2 heard
No murmurs
RESPIRATORY SYSTEM
No dyspnoea wheeze
Central trachea
Bilateral air entry +
Bilateral basal crepts +
CNS
Higher functions
Patient is conscious, coherent,and co-operative. Oriented to place but not to time and person. Delay in response but able to recall. Crainal nerve intact.
Examination of motor system
Tone increased on right upper limb
Not able to approximate both upper limbs
Power of muscle- normal
Coordination of movement
Tremors : resting, pill rolling movement
Reflex : (available in case report)
Sensory system: Normal
reports: (available in case report)
Case 4: ( https://dr-arefin.blogspot.com/2022/11/e-logs-medicine-hi-i-am-arefin-sadat.html )
A 39-year-old female, housewife, presented with the complain of she has been suffering from boils on her left knee for almost 6 days, she cannot hold the toilet(both defecation & micturition) for nearly 20 years, but it got severe since 2015, she can not walk properly without support for nearly 30 years.
The patient was reasonably well until the age of 8 years.
Though at the age of 9 months, she fell from the 2nd floor but was not injured at all. She was admitted to a hospital for 1 day, and then she was completely fine. After that, at the age of 8 years, she sprained her ankle while playing football. After a few days, the swelling in her leg went down but following this incident; she couldn’t walk properly without any support. Day by day, this got aggravated, and she used to fall while walking. In the beginning, they took ayurvedic treatment for almost 1 year, but as the patient's condition didn’t improve, they went to Cooch Behar at the age of 9 years for treatment purposes. Unfortunately, she was mistreated due to the wrong diagnosis. The doctor treated her as a vit-D deficiency patient, which was later correctly diagnosed in Bhopal in 2004 as a neuropathic problem. When the patient was 12 years old(1994), they went to Kolkata and did MRI, where she was told that there were no significant findings, though she was still suffering from her inability to walk properly. At the age of 15(1995), her problem suddenly went away. She was pretty well for a long time & didn’t show any abnormal movement while walking. But after giving birth to her first child(2010), a cesarean section, she again started feeling weakness in her lower limb. Later in 2012, they went to Bhopal, where they again did MRI, but this time she was diagnosed with a neuropathic problem. In Dec 2021, they went to Bengaluru, where they again did MRI & found the same findings as in Bhopal. There she was given medicine for 3 months course, and after taking that, she felt comparatively better, although all the problems still exist.
At present, she is gradually losing strength in both feet & can't stand up after sitting for a while or can't walk properly without any support. There is also severe body ache in the neck, back, and feet. She gave birth to her second baby in 2018, and following that pregnancy, the weakness in the lower limb was aggravated much more. The pain increases with work and walking.
She says that her second baby, who is now four years old, seldom speaks of 1/2 words or doesn’t talk at all with anybody.
She also complains that she cannot hold her defecation and micturition for almost 20 years, but it got severe since 2015. When her rectum or bladder becomes full, she loses control over it, and she can't hold it any longer. According to my patient's guardian, she has been suffering from this inability to hold the toilet since she sprained her leg, but this has become severe for the last 5/7 years.
She also added that for the last six days, she has been suffering from boils on her left knee. It is painful, itching in nature, and a slight discharge comes out of the spot. The site became swollen gradually and reddish. This aggravated her walking movements more severely. She also suffered from a fever(101F) 2 days back, which was subsided by medication.
This is not a known case of DM, TB, HTN, or Epilepsy.
Her father had a stroke in 2006 along with a little extent of paralysis and died in 2009, and her mother is hypertensive for almost 4 years.
Report: (available in case report)
Case 5: ( https://dr-arefin.blogspot.com/2022/11/59f-with-als.html )
A 59-year-old female, employee of a company, presented with the complain of she lost the strength of both her upper & lower limbs, including her waist & fingers, for 5 months which got severe in the last month, cannot walk for 1 month, lost her balance for 1 month.
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 .
Report: (available in case report)
Diagnosed with ALS
Case 6: ( https://dr-arefin.blogspot.com/2023/03/37m-snake-bite.html )
37 year old male, garbage collector in profession, with no significant past history, came to hospital with the complain of bowel bladder accidents frequency and mitigation, barely able to walk and numbness of lower limb. History states that in 2013, on one evening around 7pm he went to the fields to empty his bladder and stepped on a snake (?russel viper) which bit his leg. He lost consciousness and doesn’t remember anything. Bystanders told him that he vomited, passed urine and stools in his clothes, swelling of left lower limb and was taken him to the nearby herbal medicine doctor who gave him herbal medicines. Gained consciousness in the morning. He used herbal medicines for five months and his left lower limb swelling subsided gradually. After swelling subsided and patient started going back to workstation he noticed numbness and sensation loss in his right leg which worried him but did not get any aid and carried on his daily activities. In 2017 he had insidious onset of urinary and stool incontinence, erectile dysfunction which was gradually progressive. Due to affordability issues he went back to his town and consulted a local mbbs doctor who took an X-ray and advised him medications(unknown) for 10 days. Patient had no relief and went for herbal medications which he trusted would cure him. But patient had no improvement with herbal medicines. Patient stopped going for work outside since then and sits idle at home. He tried homeopathy medicine for one month. On advice of homeopathy doctor he stopped consuming alcohol since two months but because of cravings he still drinks on Sundays. Bought a garbage van and hired a man to collect garbage through which he earns a little amount and runs the family. Sometimes patient have anxiety and feels generalised weakness. Worried about his children future. At times he feels taking off his life would be better than to be bed ridden. He also feels low and his pride hurt for not been able to perform sexual activities. His concern to be able to get back to normal and carryon his daily activities.
Discussion:
Case discussion:
Case 1:
Case 2:
Case 3:
Case 4:
Case 5:
Subheading:
Subheading:
Subheading:
Conclusion:
Disclosure of conflict of interest:
Referrence:
....
Medical cognition system 1 and 2
PaJR
CBBLE
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