General medicine case-2
21 /09/2021
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.A 65 year old Male,resident of Rajamalkapur toddy climber by occupation presented to causality with chief complaint of sudden onset of unable to stand ,unable to sit,unable to lift the head from pillow since 10 days which is associated with neck pain and backache .
History of present illness:-
Patient was apparently asymptomatic 10 days back ,then he had generalized weakness,neck pain,backache,pain while raising the legs associated with decrease sensation right upper limb .
Patient has lots of pain when he is trying to lift his head from pillow.
Patient has pain even when he tries to get from bed.
Wasting of muscles on right hand and claw hand appearance is seen.
Patient had a h/o thorn pricking to left 2nd toe followed by blackish discoloration 10 days back.
H/o burning micturition 2 months back and diagnosed as renal failure.
No h/o fever
Bowel bladder movements normal
Not a known case of diabetes, hypertension, ckd.
Hansen's disease under evaluation with pre renal aki.
Personal history:-
Mixed diet
Alcoholic
Pt has Habit of smoking
Loss of apetite than before
General examination:-
Patient was conscious,coherent,cooperative.
No icterus, cyanosis.
No clubbing,lymphadenopathy.
Pallor present .
Vitals
Temp - afebrile
BP - 120/80 mmhg
PR - 88 bpm
RR - 18 cpm
SpO2 - 99
CVS - S1 S2 heard
Per Abdomen- soft, non tender
Systemic examination:-
Cranial nerves - normal
Sensory system - decreased on right upper limb from C5 to C7 ( shoulder upto palm )
Motor system - Tone normal
Reflexes :-
Right Left
Biceps Couldn't elicit 3+
Triceps 2+ 3+
Supinator - 1+
Knee 2+ 2+
Ankle - -
Plantar Withdrawal
Muscles power:
Right Left
Upper limb
Elbow - Flexor 5/5 5/5
- extensor 5/5 5/5
Wrist - Flexor 5/5 5/5
- extensor 5/5 5/5
Hand grip 4/5 4/5
Lower limb
SLRT 70⁰ 40⁰
Hip - Flexors 5/5 5/5
- extensors 5/5 5/5
Knee - Flexors 5/5 5/5
- Extensors 5/5 5/5
Ankle - DF 4/5 4/5
- PF 4/5 4/5
EHL 3/5 3/5
FHL 3/5 3/5
Sensation ++ ++
Provisional diagnosis:-
Compressive myelopathy secondary to prevertebral access/ soft tissue D1 - D3 ? Space occupying lesion D11 - L1 with mild C5 - C6 cord compression .
Investigations:-
Ecg:
Hemogram :-
Hb - 9.9
TLC - 14000
RBC - 3.94
Platelet count - 6 lakh
PCV - 31.2
CUE :-
Albumin- trace
Sugar - nil
Pus cells - 2 - 3
Epithelial cells - 2- 3
Red cells - nil
LFT :-
TB - 1.7
DB - 0.5
AST - 36
ALT - 49
ALP - 582
TP - 7.6
Albumin - 2.4
RBS - 80
RFT :-
Urea - 168
Creatinine - 3.5
Serum Na - 133
Serum K - 6
Serum Cl - 90
Serology -negative.
Treatment:-
18th sep:
IVF:1ns. With 1amp optineuron
T.pan 40mg/po/od
T.ultraset/po/tid
Soft collar
NBM till further orders to plan for contrast MRI.
T.MVT po/od
Nebulization with salbutamol 4th hourly.
Questions:-
Why there was sudden onset of this problem?
What might be the cause of compressive myelopathy in this patient? Is it due to aging ?
Case taken by:
A.Rashmitha(09)
A.Shruthi (04)
