1000013550.jpg
Give present medical history
analyse_media
The analysis tool returned metadata rather than clean text. I can clearly read the handwritten document from the image directly. Here is the full transcribed present medical history:
Present Medical History
Patient: 15-year-old male, resident of Kalyan
Chief Complaint / History of Presenting Illness:
- Alleged history of 2 months back, the patient had weakness in bilateral lower limbs, which was of insidious onset, gradually progressive.
- After a few days, the patient also had difficulty in maintaining balance while walking (due to this).
- The patient went to a nearby hospital; the doctor gave medicine (DNA - details not available); the patient showed no improvement and went to another hospital, where investigations were done on 3/7/26.
Investigations Done (3/7/26)
1. Nerve Conduction Study (NCS):
"There is evidence of sensorimotor demyelinating with secondary axonal polyneuropathy affecting bilateral upper and lower limbs."
2. MRI Dorsolumbar Spine:
"Subtle T2 hyperintense signal intensity in posterior aspect of thoracic cord T5 to T11, without contrast enhancement or cord expansion - ? Myelopathy."
Clinical Assessment:
On the basis of the above investigations and clinical evaluation, the patient was diagnosed (diagnosis not fully legible, but implied by the combination of NCS + MRI findings - likely Guillain-Barre Syndrome / CIDP with concomitant myelopathy, or a combined central + peripheral demyelinating disorder).
Summary Table
| Feature | Detail |
|---|---|
| Age / Sex | 15-year-old male |
| Residence | Kalyan |
| Duration | 2 months |
| Onset | Insidious, gradual progression |
| Primary complaint | Bilateral lower limb weakness |
| Associated symptom | Balance difficulty while walking |
| NCS finding | Sensorimotor demyelinating + secondary axonal polyneuropathy (bilateral UL + LL) |
| MRI finding | Subtle T2 signal in posterior thoracic cord T5-T11, no enhancement, no expansion - ? Myelopathy |
| Investigation date | 3 July 2026 |
This is a shared conversation. Sign in to Orris to start your own chat.