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

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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, and investigations, and come up with a diagnosis and treatment plan.

A 36 YR OLD MALE FISH VENDOR BY OCCUPATION CAME TO OPD WITH

CHIEF COMPLAINTS :

THE PATIENT MET WITH AN ACCIDENT ON 7.03.23 (HOLI)

- WEAKNESS IN BILATERAL UPPER AND LOWER LIMBS SINCE 3 MONTHS

- RETENTION OF URINE SINCE 3 MONTHS

-DECREASED SENSATION ON LOWER LIMBS - 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 :

MARITAL STATUS: 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: 86 bpm

Rr:18 cycles /min

BP: 130/80 mm of hg

SYSTEMIC EXAMINATION :

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

NEUROLOGICAL EXAMINATION :

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

Examination Videos :

clonus:

Knee jerk :

Tricep reflex:

Ankle jerk:

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.