20100006005 LONG CASE

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CASE :

21 year old woman, working as a nurse in an outside hospital, residing at Nalgonda presented to casualty on 26/8/2021 with the chief complaints of

Fever since 4 months

Generalized weakness since 4 months

Cough since 1 month

Vomitings 2 episodes since 1 day

Unable to walk since 1 day

Unable to pass urine and stool since 1 day

H/O PRESENTING ILLNESS

She was born out of a non consanguinous marriage. She cried immediately after birth.

At birth - she was in the hospital for 2 - 3 days for jaundice later recovered and no complications were noted.

Her father works as a shop keeper and her mother works at a chaat bhandar. She has 2 elder sisters, both of her sisters works as the nursing staff.

She was apparently alright until 1 year back when she noticed swelling in her neck after for which she went for a checkup to a local hospital where she got diagnosed to be hypothyroid. She was started on Tab thyronorm 100mcg once daily.

Few months later she developed generalized weakness for which she paid a visit to a local hospital where in she was diagnosed with ? Iron deficiency anemia for which she used iron and vitamin supplementation for 2 days and stopped on her own.

4 months back she developed low grade fever for 1 week which was low grade ,nocturnal in variation, not associated with any night sweats and was relieved by medications. Since then she has been experiencing low grade fever intermittently. She started experiencing generalized weakness and loss of appetite.

She also tells us that she started experiencing extreme body pains to an extent that she stopped going to work.

Since 1 month she has been having cough with scanty, non blood tinged mucoid expectoration.

She paid a visit to a local hospital and received symptomatic treatment for a week.

1 day back she had 2 episodes of non projectile, non bilious,

non blood tinged Vomiting.

On 26th of this month, she suddenly fell off from her bed at 7am in the morning when she tried to get up from her bed. Her mother and father had to lift her up and put her on the bed. She was unable to raise her bilateral lower limbs. Though she was able to move her toes with difficulty. Few hours later she started experiencing tingling sensation in her bilateral lower limbs. They assumed it was due to her generalized weakness and loss of appetite so she wasn't taken to any hospital. She even didn't pass urine and stool since morning. By evening after noticing that their daughter couldn't get up from her bed her parents got alarmed and got to our hospital.

On further questioning:

She gave no complains of difficulty in combing her hair, no difficulty in mixing of food.

She had difficulty in getting up or turning/rolling in the bed

No H/o altered sensorium, loss of consciousness, seizures.

She gave no complaints of loss of smell, vision, diplopia or eye movements, squint , inability to close eyes

no difficulty in chewing, loss of sensation over the face,

No loss of taste, hearing , tinnitus ,vertigo, ear fullness

No difficulty in swallowing, nasal regurgitation ,nasal twang of voice

No difficulty in shrugging shoulders ,turning neck to one side.

No deviation of tongue on protrusion.

No H/o trauma ,injury .

No H/o recent vaccination or dog bite.

No history of any radiation exposure.

No history of chronic radicular back pain.

No history of arthralgia , photosensitivity.

No H/o unilateral or bilateral swelling of lower limbs

No H/o acute onset of breathlessness.

She says that she lost around 10kgs over the past 6 months

Past history:

No history similar episodes in past .

No significant surgical or medical history.

PERSONAL HISTORY:

Diet - mixed

Appetite - decreased since 4 months

Bowel and bladder - unable to pass

No addictions

FAMILY HISTORY : No significant family history.

Summary:

GENERAL EXAMINATION:

On presentation to us:

Patient was examined in well lit room in supine position ,

Thin built woman, poorly nourished ,

Conscious, cooperative , well oriented to time ,place ,person.

She had pallor

Her vitals were stable

Afebrile to touch ,

Blood pressure : 120/80 mmhg taken in supine , rightness brachial artery.

Pulse rate : 74/min right radial artery , rhythm and volume were normal, no radio radial delay or radio femoral delay,no apex pulse deficit , all peripheral pulses are felt.

Respiratory rate - 16 /min thoraco abdominal type.

GCS - 15/15

MMSE of 30/30

No raised JVP.

CRANIAL NERVES

CRANIAL NERVE	TEST	RIGHT	LEFT
I	Sense of smell i) Coffee	+	+
II	i) Visual acuity – Snellen Chart ii) Colour vision – Ishihara chart iii) Fundus	6/6 Normal Normal	6/6 Normal Normal
III, IV, VI	i) Extra-ocular movements ii) Pupil – Size iii) Direct Light Reflex iv) Consensual Light Reflex v) Accommodation Reflex vi) Ptosis vii) Nystagmus viii) Horners syndrome	full 3mm Present Present Present Absent Absent No	full 3mm Present Present Absent Absent No
V	i) Sensory -over face and buccal mucosa ii) Motor – masseter, temporalis, pterygoids iii) Reflex a. Corneal Reflex b. Conjunctival Reflex c. Jaw jerk	Normal Normal Present Present Present	Normal Normal Present Present Present
VII	i) Motor – nasolabial fold occipitofrontalis orbicularis oculi orbicularis oris buccinator platysma ii) Sensory – Taste of anterior 2/3rds of tongue(salt/sweet) Sensation over tragus iii) Reflex – Corneal Conjunctival iv) Secretomotor – Moistness of the eyes/tongue and buccal mucosa	Present Good Good Good Good Good Normal Normal Present Present Normal	Present Good Good Good Good Good Normal Normal Present Present Normal
VIII	i) Rinnes Test ii) Webers Test iii) Nystagmus	Positive Not lateralised Absent	Positive Absent
IX, X	i) Uvula, Palatal arches, and movements ii) Gag reflex iii) Palatal reflex	Centrally placed and symmetrical Present Present	Present Present
X1	i) trapezius ii) sternocleidomastoid	Good Good	Good Good
XII	i) Tone ii) Wasting iii) Fibrillation iv) Tongue Protrusion to the midline and either side	Normal No No Normal	Normal No No Normal

Bulk - Right Left

Mid arm 18cm 18cm

Forearm 13cm 13cm

Mid thigh 26cm 26cm

Leg 18.5cm 18.5cm

Tone

UL Reduced bilaterally

LL Reduced bilaterally

Power

III – POWER

a. Neck muscles

b. Upper limbs

i) Shoulder

Flexion-Extension

Lateral Rotation-Medial Rotation

Abduction -Adduction

ii) Elbow

Flexion-Extension

iii) Wrist

Dorsi flexion-Palmar flexion

Abduction-Adduction

Pronation-Supination

iv) small muscles of hand

v) Hand grip

c. Lower limbs

i) Hip

Flexion-Extension

Abduction-Adduction

Lateral Rotation-Medial Rotation

ii) Knee

Flexion-Extension

iii) Ankle

Dorsi flexion-Plantar flexion

Inversion-Eversion

iv) Small muscles of foot

d. Trunk muscles

e. Beevor’s sign

Good

4+/5

Good

2/5

Weak

Good

4+/5

Good

2/5

Weak

LOCAL EXAMINATION

1)Neck

Flexion 5/5

Extension 5/5

2) Shoulder

Abduction -

RIGHT Left

Supraspinatus . 4+/5 4+/5

Deltoid . 4+/5 4+/5

Infraspinatus . 4+/5 4+/5

Lattismus dorsi . 4+/5 4+/5

Serratus anterior . 4+/5 4+/5

Pectoralis major . 4+/5 4+/5

Rhomboid. . 4+/5 4+/5

3) Elbow

Biceps . 4+/5 4+/5

Triceps . 4+/5 4+/5

Brachiradialis . 4+/5 4+/5

4) Wrist

Flexor carpi radialis . 4+/5 4+/5

Flexor carpi ulnaris . 4+/5 4+/5

Extensor carpi radialis longus . 4+/5 4+/5

Extensor carpi ulnaris longus . 4+/5 4+/5

Extensor digitorum . 4+/5 4+/5

5)Handgrip

Abductor pollicis longus 4+/5 4+/5

Abductor pollicis brevis 4+/5 4+/5

Extensor pollicis longus 4+/5 v 4+/5

Extensor pollicis brevis 4+/5 4+/5

Oppenens pollicis longus 4+/5 4+/5

Opponens pollicis brevis . 4+/5 4+/5 .

Adductor brevis . 4+/5 4+/5 .

Dorsal interossei . 4+/5 4+/5 .

Palmar interossei . 4+/5 4+/5 .

6) Trunk Abdomen

Able to roll but unable to get up from the bed on her own

7) Hips

RIGHT LEFT

iliopsoas 4-/5 4-/5

Adductor femoris 4-/5 4-/5

Abductor femoris 4-/5 4-/5

Gluteus maximus 4-/5 4-/5

Gluteus medius 4-/5 4-/5

8)KNEE

Internal rotators . 4-/5 4-/5

External rotators 4-/5 4-/5

Extension 4-/5 4-/5

Flexion 4-/5 4-/5

9)Ankle

Dorsiflexion . 4+/5 .4+/5

Plantar Flexion. . 4+/5 . 4+/5

External rotation . 4+/5 . 4+/5

Internal rotation . 4+/5 . 4+/5

Vibration 5.3 seconds 8seconds

Ankle. 6 seconds. 6seconds

Medial malleolus. 6seconds. 6seconds

TibiaL tuberosity. 6seconds. 06 seconds

Elbow 7seconds. 07 seconds

Crude touch Normal. Normal

Temperature able to perceive heat and cold

Fine touch. Normal normal.

Romberg sign. mild swaying to right

Proprioception. Decreased 3-4/10 9/10

Stereognosis good good

Tactile localisation. Normal normal.

Two point discrimination present present

UL 4+/5 4+/5

LL 2/5 2/5

Reflexes

B - -

T - -

S - -

K - -

A - -

P Extensor bilaterally

Abdominal reflex - Absent

SENSORY SYSTEM previous admission

TEST	RIGHT	LEFT
I – SPINOTHALAMIC 1. Crude touch 2. Pain 3. Temperature II – POSTERIOR COLUMN 1. Fine touch 2. Vibration 3. Position sense 4. Romberg’s sign III – CORTICAL 1. Two point discrimination 2. Tactile localisation 3. Graphaesthesia 4. Stereognosis	Reduced Reduced Reduced Reduced Reduced Lost Unable to perform Lost Lost Lost Normal	Reduced Reduced Reduced Reduced Reduced Lost Unable to perform Lost Lost Lost Normal

Priopioception lost upto the level of ankles

Vibration: Reduced in the lower limbs, more on the right side

Right Left

Great toe 3 secs 4 secs

Ankle 3 secs 8secs

Knee 6 secs 8secs

Wrist 10 secs 11 secs

Elbow 11 secs 12 secs

Fine touch - + +

Crude touch:

On right side she complained of reduced touch on her right thigh

Spinal Tenderness- present throughout all the levels of spine

Cerebellar signs - absent

No involuntary movements present.

Lungs - Reduced breath sounds bilaterally in all the lung fields

Cvs - S1,S2 +

Per Abdomen-

Bowel sounds +

Her weakness aggravated since yesterday

She also complains of neck stiffness

Neck stiffness-

Kernigs sign -

brudzinskis sign -

28/09/2021

Power is now 0/5 in both the lower limbs next day

Reflexes - Bilateral finger flexion + on Biceps and supinator examination

Lower limb reflexes absent

Abdominal reflex absent

Sensory system:

Vibration Reduced upto the level of hip joint ( lesser on the right side)

Proprioception absent upto the level of ankles

Couldn't appreciate fine and crude touch below the level of umbilicus

Extraocular muscles - normal

Pupils bilaterally reacting to light

All the other cranial nerves normal

Investigations:

Hemogram:

RBC: 4.09

WBC: 12300

Hb- 8.4

PLT- 4.8 lakh

Aptt- 32 sec

PT - 16 sec

INR. - 1.11

BT - 2 min

CT - 4 min

ESR - 90 mm in 1st hr

CUE:

Albumin- nil

Sugars- nil

Pus cells - 2 to 3

Epithelial cells - 2 to 3

Blood urea- 22 mg/dl

Serum creatinine - 0.6 mg/dl

TB- 0.70 mg/dl

DB. - 0.19 mg/dl

Na+ - 132 meq/lit

K+ - 3.4 meq/lit

Cl- : 94 meq/lit

ALP: 236 IU/lit

SGOT: 13 IU/LIT

SGPT: 10 IU/LIT

Serum protein: 6.5 gm/dl

Serum magnesium: 2.2 mg/dl

Serum calcium: 9.6 mg/dl

Serum albumin: 2.4 gm/dl

Covid-19- Negative

Peripheral smear- Microcytic hypochromic anemia with leucocytosis

MRI BRAIN IMPRESSION- Acute infarct involving the genu of the corpus callosum on the left side

Provisional diagnosis:

H/O PULMONARY KOCH'S

B/L PARAPLEGIA

probable differentials :

1) transverse myelitis ? non compressive etiology

2) amyotrophic lateral sclerosis

3) Multiple sclerosis (rare)

4) NMO spectrum diseases

5) GBS

5) Friedrichs ataxia ( very rare)

Investigations-

X ray on 14-09-2021

X ray on 20-09-2021

ECG-

Standard 12 lead ECG with normal voltage and speed @ 25mm/s; P waves, QRS complexes and T waves have normal morphology and duration; P-P and R-R intervals are normal. PR and QTc intervals are normal.

Usg on 26-08-2021