80 YEAR OLD MALE WITH C/O WEAKNESS OF BOTH UPPER AND LOWER LIMBS
80/ M FARMER BY OCCUPATION
PATIENT CAME TO CASUALITY WITH C/O WEAKNESS OF BOTH UPPER LIMB AND LOWER LIMBS.
- C/O FEVER SINCE 2 DAYS WHICH WAS ON AND OFF , HIGH GRADE WHICH EVENTUALLY GOT REDUCED
HE WENT TO LOCAL RMP, AND FOUND TO BE HIGH BP ( NO DOCUMENT AVAILABLE) TAKEN SOME MEDICATION ( UNKNOWN) . PATIENT HAD HIS DINNER ON 01/02/22 @8PM AND WENT TO BED AND A/H/O FALL FROM BED SINCE THEN HE IS UNABLE TO MOVE HIS BOTH UL AND LL.
-NO C/ O SLURRING OF SPEECH, DEVIATION OF MOUTH.
- NO C/ O INVOLUNTARY MOVEMENTS , TONGUE BITE , FROTHING FROM MOUTH.
- NO C/ O HEAD INJURY / VOMITINGS
- NO C/O CHEST PAIN, PALPITATIONS, SYNCOPAL ATTACKS
- NO C/O SOB , ORTHOPNEA , PND
- NO C/O ABD PAIN , BURNING MICTURITION
- NO C/O DIFFICULTY IN SWALLOWING.
TREATMENT HISTORY :-
NOT SIGNIFICANT
PERSONAL HISTORY:-
PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE , WELL ORIENTED TO TIME, PLACE , PERSON
APPETITE- NORMAL
DIET - MIXED
BOWELS - INVOLUNTARY MICTURITION AND INVOLUNTARY DEFECATION PRESENT .
- TEETOTALER AND A SMOKER
FAMILY HISTORY:-
NOT SIGNIFICANT
GENERAL EXAMINATION:-
- PALLOR PRESENT
- NO CYANOSIS , LYMPHADENOPATHY, ICTERUS, CLUBBING , ODEMA
VITALS:-
BP:- 190/100MMHG
PR:- 92BPM
SPO2:- 96% AT RA
ON EXAMINATION:-
CVS:- S1S2 HEARD , NO MURMURS
RS:- BAE PRESENT , NVBS
P/A :- SOFT , NON TENDER
CNS:-
- CONSCIOUS, ALERT
SPEECH :- NORMAL
RIGHT. LEFT
POWER UL 0/5. 0/5
LL. 1/5. 1/5
TONE. UL. -DECREASED -
LL. -NORMAL-
REFLEXES
RIGHT LEFT
BICEPS. - -
https://youtube.com/shorts/5QzistLNrQc?feature=share
TRICEPS. - -
https://youtube.com/shorts/lrxUKgRqsCQ?feature=share
https://youtube.com/shorts/8uB9h3evL8Y?feature=share
SUPINATOR. - -
KNEE +. +++
https://youtube.com/shorts/dtRNWPbtN7E?feature=share
ANKLE. +. +
https://youtube.com/shorts/vt1TG_4Kzvo?feature=share
https://youtube.com/shorts/3q_w0GVypFg?feature=share
JAW JERK + +
PLANTARS - MUTE
https://youtube.com/shorts/U-3yggOMdyQ?feature=share
https://youtube.com/shorts/PmQVc_J6SCA?feature=share
SENSORY - DEEP PAIN ABSENT BELOW NIPPLE LEVEL
INVESTIGATIONS:-
HEMOGRAM-
HB:- 8.3GM/DL
TC:- 5,300
N/L/E /M :- 95/ 02/01/02
PCV :- 25.6
MCV- 80.5
MCH:- 26.1
MCHC:- 32.4
RBC :- 3.18
PLATELETS:- 4.72
NORMOCYTIC NORMOCHROMIC ANEMIA WITH NEUTROPHILIC LEUCOCYTOSIS.
COMPLETE URINE EXAMINATION:-
PUS CELLS- 3-4
EPITHELIAL CELLS - 2-3
ALBUMIN:- TRACE
SUGARS:- NIL
RBS- 162MG/DL
FBS:- 144MG/DL
PLBS:- 126MG/DL
LFT:-
TB:- 0.55
DB:- 0.18
AST:- 19
ALT:- 10
ALP:- 135
TOTAL PROTEIN:- 5.7
A/ G RATIO:- 0.96
RFT:-
BLOOD UREA -52
SERUM CREATININE - 0.9
Na:- 137
K:- 5.8
Cl:- 102
HBA1C:- 6.6 %
FASTING LIPID PROFILE:-
TOTAL CHOLESTROL:- 112MG/DL
TRIGLYCERIDES:- 174 MG/DL
HDL CHOLESTEROL:- 30MG/DL
LDL CHOLESTROL:- 89 MG/DL
VLDL:- 35MG/DL
ECG:-
USG ABDOMEN :-
IMPRESSION:- B/L GRADE 2 RPD WITH SIMPLE CORTICAL CYSTS
USG CHEST:-
IMPRESSION:-
1) RIGHT MILD PLEURAL EFFUSION
2) LEFT MILD PLEURAL EFFUSION WITH FEW CONSOLIDATORY CHANGES IN PERIPHERAL LUNG PARENCHYMA
2D ECHO:-
IMPRESSION:-
EJECTION FRACTION:- 48%
MILD LV DYSFUNCTION
DIASTOLIC DYSFUNCTION , MILD PAH
DILATED RA / LA/ RVH
MRI :-
IMPRESSION:-
1) MODERATE TO SEVERE CERVICAL SPONDYLOSIS AT MULTILEVEL C2-C3 , C3-C4 , C4-C5 & C5-C6 LEVEL WITH COMPRESSIVE MYELOPATHY CHANGES AND SPINAL CANAL STENOSIS
2) NEURAL IMPRINGEMENT AT C4-C5 , C5-C6 LEVELS.
PROVISIONAL DIAGNOSIS:-
? COMPRESSIVE CERVICAL MYELOPATHY
TREATMENT PLAN:-
1) IV FLUIDS @75 ml/hr
2) CERVICAL HARD COLLAR
3) TAB AMLONG 5MG PO/OD
4) TAB PAN 40MG PO/OD
5) TAB ZOFER 4MG PO/ SOS
6) BP/ PR/ RR / TEMP CHARTING
7) STRICT IPO CHARTING
8) INJ OPTINEURON 1 AMP IN 100ML NS / IV / OD
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