Continuation to the case study. :)
So any supporters for South Korean in the FIFA soccer world cup?

Differential Diagnosis
Madam XXX is likely to have painful pheripheral neuropathy on all 4 limps and I would like to propose the following aetiologies
1) Toxic causes
In view of her recent intake of ciprofloxacin although this is not a common agent that causes peripheral neuropathy.
Possible poisoning by toxins like arsenic are such substances are sometimes found in high levels in traditional Chinese medication.
2) Inflammatory Causes
She recently had a gastrointestinal infection which could lead to a sequelae of inflammatory demyelinating disease, although this usually presents with more motors symptoms. An atypical presentation of Acute Inflammatory Demyelinating Polyradiculoneuropathy(AIDP) is possible
3) Autoimmune causes
Autoimmune causes are possible although she has not showed any other signs of an autoimmune disease. This is more important since she had a recent allergic reaction to ciprofloxacin.
Other etiologies to consider:
Diabetic amyotrophy
Although the course is usually more chronic.
Nutritional Causes
Vitman B12 and folate are possible causes although the course is also usually more chronic and chronic deficiency of are not common in Singapore.
AIDS related neuropathy
The history does not suggest this, however it is noted that true sexual history of the patient and her partners are not easy to elicit.

Continuation to the case study. :)
So any supporters for South Korean in the FIFA soccer world cup?

Differential Diagnosis
Madam XXX is likely to have painful pheripheral neuropathy on all 4 limps and I would like to propose the following aetiologies
1) Toxic causes
In view of her recent intake of ciprofloxacin although this is not a common agent that causes peripheral neuropathy.
Possible poisoning by toxins like arsenic are such substances are sometimes found in high levels in traditional Chinese medication.
2) Inflammatory Causes
She recently had a gastrointestinal infection which could lead to a sequelae of inflammatory demyelinating disease, although this usually presents with more motors symptoms. An atypical presentation of Acute Inflammatory Demyelinating Polyradiculoneuropathy(AIDP) is possible
3) Autoimmune causes
Autoimmune causes are possible although she has not showed any other signs of an autoimmune disease. This is more important since she had a recent allergic reaction to ciprofloxacin.
Other etiologies to consider:
Diabetic amyotrophy
Although the course is usually more chronic.
Nutritional Causes
Vitman B12 and folate are possible causes although the course is also usually more chronic and chronic deficiency of are not common in Singapore.
AIDS related neuropathy
The history does not suggest this, however it is noted that true sexual history of the patient and her partners are not easy to elicit.

World Cup

Hmm, wierdly not many people seems to be intersted in medical case reports. I wonder if it's because majority are having their summer break now.
How about talking about world cup statistic, about rates and bets?

Today will be the Physical Examination section

Physical Examination
Madam XXX’s physical examination shows signs of peripheral neuropathy.
I say this because on her palmar and dorsum of her hands and on her lower limbs from knew down bilaterally, she has decreased pin prick sensation and a loss of vibration sensation. Her proprioception was lost in her lower limbs but was intact in her upper limbs. Also she showed dry skin on her hands and feet which might suggest an autonomic involvement.
She feels pain when she touches her own hand and it is worst on the pulp of her fingers.
Her tone was normal on all four limbs. She had brisk biceps, triceps and knee reflexes and absent Supinator and ankle reflex. Plantar reflexes could not be elicited.
Her power was weak at about 4 for her proximal muscles and 3+ for her distal muscles in both her upper and lower limbs. Although it should be noted there seemed to be variable effort on testing and that her power of her lower limbs were inconsistently weak as compared to her ability to walk.
She showed no cerebellar signs and was Romberg positive. She was able to walk although she was somewhat atypically unsteady.
Other neurological and abdominal examination revealed no abnormalities.
There were no dermatological signs suggesting any autoimmune disease.
She did not show any signs suggesting endocrine disorders of the thyroid and diabetes.
Other systems examined were also normal.

Sumamry
In summary, Madam XXX shows signs of glove and stocking painful peripheral neuropathy affecting pain, vibration, proprioception and possibly autonomic functions of her limbs bilaterally. Her power was weak but seemed to be effort related.

Case Reports

As a Medical student,I do many medical case reports every year and I think they are a good way to learn. However, I relise little people actually share their reports although doing so would be a very good way to learn from each other.

I shall start today wittg the History of a Neurological problem. No identities or names are published.

CASE WRITEUP 1 (Neurology)

Presenting complain.
Madam XXXis a 40 year old lady who was admitted to neurology for numbness of her distal upper and lower limps bilaterally, accompanied by allodynia of her palmar surface of her hands. She also complains of weakness of her hands and foot bilaterally.
Her symptoms of numbness, allodynia and weakness started 3 weeks ago, accompanied by rashes which were papular and appeared all over her body. These symptoms started a day after she started on Ciprofloxacin which was given to her for suspected gastroenteritis which started 4 weeks ago. The numbness has since not resolved although it did not worsen.
Her numbness was localized to her dorsal and palmar surface of both her hands and to the bilateral lower limps from knee downward. Her numbness was so severe that she did not realize that she suffered a burn on the dorsum of her left hand. She complains that the numbness of her legs has caused her to feel unable to balance. The numbness remained there throughout the day.

When Madam XXX touches her palmar surface of her hand, she feels what she describes as “chisel” pain, which upon explanation is the kind of pain when someone lies on his own hands for a long time. This pain was brought on by simple activities of shaking hands or using the mobile phone’s keypad to send an instant message. The pain will not be present so long as she does not touch anything. The pain is worst on the pulps of her fingers and is equal in both her hands. The allodynia started with the numbness and has not gotten worst or better since then.
Also, Madam XXX feels that she is weaker in the power of her hand muscles and foot since the numbness started. She claims that she has difficulty when carrying gripping objects with her hands and feels weak and less able to balance when she walks.

Other Significant history

This is Madam XXX 3rd hospitalization in a month.
She was first admitted 4 weeks ago on the 6th of May for diarrhea, vomiting and dehydration. During that episode, she also complained of central epigastric pain which comes on and off for a few months and also black watery stools. She was treated for her dehydration and for gastroenteritis and discharged after 5 days with ciprofloxacin.

1 day after taking ciprofloxacin, she realized that she had rashes all over her body. Also she started to feel numbness of her hands and legs together with allodynia and weakness of her limbs as described above. She came to the hospital immediately as she suspected an allergic reaction and was admitted.
During the admission, she was found to be anemic during a full blood count and further investigations revealed a bleeding gastric ulcer. Her rashes resolved after a few days and she was treated for her gastric ulcer disease. However, she was not started on any antibiotic therapy.
Her numbness, allodynia and weakness remained after she was discharged but she assumed it’ll go away with time. She complained to Gastroenterologist about the symptoms of numbness not resolving during her follow up 1 week ago on the 3rd of may and was then advised to be admitted.

Past History
She was hypertensive for 10 years and has been on regular follow up with her GP.
She has no history of diabetes or thyroid diseases.
She has no other significant medical history of note

Social History
She does not smoke and does not drink.
She lives with her husband who is a lorry driver and her 4 daughters. Her eldest daughter is working while the other 3 are schooling and she has no financial or family problems.
Her husband has been her only sexual partner for her life.
She is not a vegetarian and takes a normal diet.


Occupational History
She works as a ward attendant in Ang Mo Kio Community hospital. She does not handle any organic solvents or toxic substances other than the normal soap and detergent.

Family History
She has no family history of peripheral neuropathy.

Drug History
She is allergic to Ciprofloxacin.
She used to take Jamu( traditional medicine) for women vitality and strength which she bought off a traditional medicinal shop but has stopped 6 years ago. She does not know the constituent of the Jamu.

Summary
In summary, Madam XXX presents with 3 weeks of numbness, allodynia and distal limb weakness. She was treated for an gastroenteritis 3 weeks ago with ciprofloxacin which she was found to be allergic to, and had taken Jamu frequently 6 years ago.