A 36 YEAR OLD MALE CAME TO OPD WITH CHIEF COMPLAINS OF WEAKNESS IN BOTH UPPER AND LOWER LIMBS

16/06/23

Hi, I am shaik karishma , 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

I have been given this case 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.

CHIEF COMPLAINTS : 

The patient met with an accident on  7.03.23 

 Weakness on bilateral upper and lower limbs since 3 months

Retension of urine since 3 months 

Decresead sensation on lower limbs since 3 months

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 3 months back then he met an RTA skid and fall from 2 wheeler on 7.03.23 (Holi) around 9:00pm. He has taken 250ml of alcohol before driving. As soon as the accident happened, he got unconscious and was taken to a local hospital, where it was said that he injured his back and neck. he was unconscious for a whole day. He gained consciousness in 24 hrs and observed that he was unable to lift both of his upper and lower limbs. He also couldn't move his neck. 

on 10.03.23, as the symptoms were still persisting patient has gone to another hospital, where an NCCT of the brain was done. it has ruled out the presence of any head injury.

later, an MRI OF SPINE spine was done, which suggested disc bulges at L4-L5, L5-S1 and C3-C4, C4-C5.patient was advised physiotherapy.

the patient also experienced decreased sensation in the lower limb i.e. decreased ability to feel the cold and hot water while bathing. he was not able to sit initially after the accident but now he can sit on his own without an attendant

he also complained of tightness around a part of his trunk -band like sensation

he was not able to comb his hair or button his shirt

he is not able to squat or wear his slippers 

he is able to roll over the bed 

he is able to take his head off the pillow 

the is no diurnal variation of weakness.

The patient also complained of Retention of urine able to feel the fullness of the bladder but is unable to initiate micturition for which a catheter is inserted since 2 months

At the time of the accident patient was unable to move his toe but later in the course of 1 and half months now he was able to move his legs and arms comparatively 

No h/o visual disturbances, headache, diplopia, ptosis he is able to appreciate smell, hes able to look towards all sides no h/o sensory loss over the face, no facial deviation

No h/o auditory disturbances

No h/o restricted tongue movements

No difficulty in swallowing

No difficulty in speaking

No h/o abnormal sweating

No h/o shooting pain

No h/o headache or vomiting.

No h/o seizures

PAST HISTORY : 

h/o RTA

No h/O of similar complaints in the past 

no H/O of Dizziness while waking up from bed 

No H/O of DM, HTN, TB, EPILEPSY 

TREATMENT HISTORY:

No specific treatment 

PERSONAL HISTORY

Married

DIET: Mixed 

APPETITE: NORMAL 

SLEEP: irregular and inadequate 

Bowel movements: irregular 

Bladder: Unable to pass urine since 3 months 

No history of any allergens 

Addictions : 

Alcohol consumption since 8 yrs (2 quarters daily ) 

Tobacco chewing since 6 yrs 

FAMILY HISTORY : 

Not significant 

GENERAL EXAMINATION 

Pt is conscious, coherent, cooperative

 moderately built, and moderately nourished 

No H/O of Pallor 

Icterus 

cyanosis 

clubbing 

Lymphadenopathy 

Edema

VITALS : 

Temp: Afebrile 

PR: 89 bpm 

Rr:17 cycles /min 

BP: 120/80 mm of hg 

SYSTEMIC EXAMINATION : 

CNS

Higher mental function 

The patient is conscious well oriented to time place and person 

No delusions or hallucinations 

Dominant right hand

Cranial nerve examination:

CN 1 : smell sense RIGHT LEFT 

                                +. + 

CN 2 : visual acuity normal Normal 

CN 3 4 6 : extra ocular movement : full 

                   Direct light reflex present 

                   Consensual light reflex present 

                        Ptosis absent 

                     Accommodation reflex present 

CN 5 : Sensory : over face ,buccal mucosa : normal 

                  Motor: masseter ,temporalis : normal 

                    Reflexes :corneal : normal

                                 Conjunctival : normal 

CN7 : Motor : nasolabial fold : present 

          Reflexes: corneal conjunctival present 

 CN 8: Rinnes +

   Webers not lateralised 

    Nystagmus : absent     

CN 9 and 10 : uulva movemts normal 

Motor system:

BULK: Inspection : Decreased 

             Palpation : Decreased 

MID ARM CIRCUMFERENCE: 

Upper limb.                                 R                       L 

Proximal muscles.               22cm                      23cm

Distal muscles.                    22cm                    24cm

Lower limb                                R                           L 

Proximal muscles.                  36cm.               36cm

Distal muscles                      29cm                 31cm    

TONE: both upper limbs - hyper tonic  

           both lower limbs- hypertonic

POWER:          

 Elbow:

Flexion. 4/5. 4/5

Extension: 4-/5. 4-/5

Wrist:

Flexion:3/5. 3/5

Extension: 3/5. 3/5

Abduction : 3/5. 3/5

adduction:3/5. 3/5

HIP

Flexion:4-/5. 4-/5 

Extension. 4/5. 4/5

Knee 

Flexion 4-/5. 4-/5

Extension. 4/5. 4/5 

Plantarflexion:. 4/5. 4/5

Dorsiflexion. 4/5. 4/5

Toe. 4/5 4/5

Reflexes : 

SUPERFICIAL:

 Plantar not visualized 

Abdominal reflexes -mute 

DEEP TENDON REFLEXES :

               Rt               Lft 

Biceps : + 3             +3 

Triceps: +3.            +3

Supinator: +3          +3 

Knee jerk: +3         +3 

Ankle jerk: +2        +2 

SENSORY SYSTEM : 

Posterior column:

 fine touch - normal  

 Vibration - normal 

SPINO THALAMIC : 

Pain : decreased sensation to pain in lower limbs 

Temperature: decreased sensation to heat and cold in lower limbs 

CEREBELLAR SIGNS : 

Finger nose test : normal 

Heel knee test : unable to touch

MENINGEAL SIGNS 

neck stiffnesses. Absent 

Kernigs sign - absent 

Brudzinski sign - not visualised 

RESPIRATORY SYSTEM : 

Trachea Central 

NVBS 

No murmurs 

CVS 

S1 and s2 sounds heard

No cardiac murmurs

ABDOMINAL EXAMINATION : 

shape - scaphoid

Tenderness- no

Palpable mass - no

Liver - not palpable

Spleen - not palpable

Bowel sounds - normal 

MRI OF SPINE : 

Diffuse disc bulges are seen at L4-L5, and L5-S1 levels, causing secondary spinal stenosis.

Diffuse disc bulges are seen at C3-C4, and C4-C5 levels, causing secondary spinal canal stenosis with mild narrowing of bilateral neural foramina with mild impingement of bilateral exiting nerve roots.

Provisional Diagnosis : 

Quadriparesis due to spinal cord injury and compression at L4-L5, L5-S1, C3-C4, C4-C5.