45 year old female with reversible paraplegia
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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, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
A 45 year old female farmer by occupation from miryalaguda came to medicine opd with chief complaints of burning micturition from 8 days ,diffuse abdominal pain and tightness from 3 days and reduced urine output from 3days
Patient was apparently asymptomatic 8 days ago then she developed burning micturition which she ignored and it is relieved by lemon juice . On19/7/2022 , as per her daily routine she woke up at 5 ;did her daily routine activities at 10:00pm she ate dal rice with pickle she slept ;at 2:00am she started having fever with chills and rigours continuously for 2hrs which is relieved by paracetamol and she got vomiting which is of non bilious, non projectile with food particles and has diffuse abdominal pain (tightness) more predominantly in left lumbar and right lumbar regions of abdomen and oliguia; there she has been treated with antibiotics and sent home. At home she drank water (6l)and she tried to urinate with difficulty , alas she got little amount of urine I.e less than 100ml for each attempt ; at 20th night ,she again got abdominal tightness and oliguria then she shifted to hospital where her usg showed cystitis(bladder will thickness of 4mm) ; she developed b/l lower limb weakness and numbness sudden in onset ; she shifted to our hospital by examination she found out she has paraplegia .Next day morning her paraplegia has cured and I examined her on 23rd
PAST HISTORY: she has history of chronic back pain at the level of T10 to L1,insidious in onset,consistent and intermittenta, is of stabbing type in character associated with fever and lower limb weakness.No h/o hypertension,diabetes,tuberculosis,asthma,epilepsy .h/o hysterectomy due to aub(polymenorrhea) at 30years
PERSONAL HISTORY:As she is a farmer; moderate physical activity ;plucking of weeds;clearing of dust she eats rice with dal/curry thrice daily with tea in between. She is more thirsty.She urinates 5-6 times at night time and she passes stool for 1time for 2days .her sleep is adequate and appetite is normal.
Family history:no similar complaints in family
Treatment history:
GENERAL EXAMINATION: Due consent was taken
On 23/6/‘22,
Patient is conscious,coherent and cooperative oriented to time place and person
Pallor,icterus,cyanosis,clubbing,lymphadenopathy,edema absent
Vitals:
temperature: afebrile
Blood pressure:110/80 in right arm in sitting position.
Respiratory rate:18 cycles per minute
Temperature:92 degree Fahrenheit
SYSTEMIC EXAMINATION:
CNS :
Right Handed person,
HIGHER MENTAL FUNCTIONS:
Conscious, oriented to time place and person.
MMSE 26/30
speech : normal
Behavior : normal
Memory : Intact.
Intelligence : Normal
Lobar Functions : Normal.
No hallucinations or delusions.
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
visual field is normal
colour vision normal
fundal glow present.
3rd,4th,6th : pupillary reflexes present.
EOM full range of motion present
gaze evoked Nystagmus present.
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR EXAMINATION: Right Left
UL LL UL LL
BULK Normal Normal Normal Normal
TONE normal normal
POWER 5/5 5/5 5/5 5/5
SUPERFICIAL REFLEXES:
CORNEAL present present
CONJUNCTIVAL present present
ABDOMINAL present
PLANTAR withdrawal withdrawal
DEEP TENDON REFLEXES:
BICEPS 2 2 2 2
TRICEPS 2 2 2 2
SUPINATOR 2 2 2 2
KNEE 2 2 2 2
ANKLE 1 1 1 1
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch
pain
temperature
DORSAL COLUMN SENSATION:
Fine touch
Vibration
Proprioception
CORTICAL SENSATION:
Two point discrimination
Tactile localisation.
steregnosis
graphasthesia.
CEREBELLAR EXAMINATION:
Finger nose test normal
Heel knee test normal
Dysdiadochokinesia absent
Dysmetria
pendular jerk absent
Intention tremor absent
Rebound phenomenon .
Nystagmus absent
Titubationabsent
Speech normal
Rhombergs test negative
SIGNS OF MENINGEAL IRRITATION: absent
GAIT:normal
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Scaphoid, with no distention.
➤Umbilicus - Inverted
➤Equal symmetrical movements in all the quadrants with respiration.
➤No visible pulsation,peristalsis, dilated veins and localized swellings.
PALPATION
➤SUPERICIAL :no local rise of temperature
➤ DEEP : liver, regular smooth surface ,
edges soft in consistency, tender, moving with respiration non pulsatile, tenderness is right lumbar and right iliac and hypo gastric regions
➤No splenomegaly
➤Abdominal girth : 78cms.
➤xiphesternum to umbilicus distance was equal to umbilicus to pubic distance.
PERCUSSIon
➤Fluid thrill and shifting dullness absent
➤puddle sign absent
➤Traubes space : resonant
AUSCULTATION
➤ Bowel sounds present.
➤No bruit or venous hum.
NO LOCAL LYMPHADENOPATHY
patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity, nose & oropharynx appears normal.
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear equal on both sides and it's Abdominothoracic type.
Trachea central in position & Nipples are in 4th Intercoastal space
No signs of volume loss
No dilated veins, scars, sinuses, visible pulsations.
Palpation:-
All inspiratory findings confirmed
Trachea central in position
Apical impulse in left 5th ICS, 1cm medial to mid clavicular line
Cricosternal distance is 3finger breadths.
MEASUREMENTS-
chest circumference- 31 inches at expiration & 32 inches at full inspiration
Chest expansion- 2.5cm
Right left
Hemithorax- 15.5 inches 15.5 inches
Hemithorax expansion- 1/2inch 1/2inch
AP diameter- 7 inch
Transverse diameter- 12 inches
AP/T ratio - 0.58
Respiratory movements equal on both sides
Tactile fremitus: normal in all quadrants
Percussion:-
Right left
Supraclavicular- Resonant (R) (R)
Infraclavicular- (R) (R)
Mammary- (R) ( r)
Axillary- (R) (R)
Infra axillary- (r) (R)
Suprascapular- (R) (R)
Interscapular- (R) (R)
Infrascapular- r() (R)
Auscultation:-
Right Left
Supraclavicular- Normal vesicular (NVBS)
Breath sounds (NVBS)
Infraclavicular- (NVBS) (NVBS)
Mammary- (NVBS) (NVBS)
Axillary- (NVBS) (NVBS)
Infra axillary- T(nvbs) (NVBS)
Suprascapular- (NVBS) (NVBS)
Interscapular- (NVBS) (NVBS)
Infrascapular- Tubular B. S (NVBS)
Abdominal Examination:tenderness noted in right lumbar and left lumbar regions and in flanks
CNS Examination:
Higher mental function tests: normal
Sensory examination: no positive findings
Motor examination: powe
reflexes https://youtube.com/shorts/Aq0RvrVOFjU?feature=share
https://youtube.com/shorts/uGVLFn-NWDk?feature=share
Differential diagnosis:lumbar stenosis; anterior spinal artery ischemic attack ; acute transverse myelopathy
Investigations:
MRI:
Prolapse at L4-l5
Grbs:
Cue: puscells-2-3
Albumin,sugars,roc,casts-nil
Electrolytes:
Sodium: 141
Potassium:4.0
Chlorine:102
Treatment:
1) inj: methylprednisololomr
2)inj: ceftriaxone
3)optineuron
4)inj pan top
5)Ivf NS and RL
6)inj.zofer
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