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

4+/5

4+/5

4+/5


4+/5


4+/5

4+/5

4+/5

Good

Good

 

 

 

2/5

2/5

2/5

 

2/5

 

2/5

2/5

2/5


 Weak


 

 

Good

 

 4+/5

4+/5

4+/5

4+/5


4+/5


4+/5

4+/5

4+/5

Good

Good

 

 

 

2/5

2/5

2/5

 

2/5


2/5

2/5

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

Usg on 14-09-2021



2D ECHO-

MRI Findings-



Treatment -


On 28-07-2021:-

1) IV FLUIDS NS,RL@100ml/hr
2) Inj.Optineuron 1ampoule in 100ml NS IV OD
3) Inj.Zofer 4mg IV/TID
4) Tab.pcm 650 mg PO SOS
5) Inj.Neomol IV SOS if temp>101°f
6) Nebulization with Duolin and budecort 6th hrly
7) Syr.Ambroxol 5ml PO TID
8) TAB.Thynonorm 50 mcg PO OD
9) TAB.Ultracet PO QID
10) TAB.Ecosporin 75mg PO H/S
11) TAB.Atorvas 10 mg PO H/S
12) TAB.Clopidogrel 75 mg PO H/S
13) Protein powder 2 spoons in 100ml milk PO /BD




Plan of care at discharge- 

1) Tab.Levipil 250 mg PO/BD
2) Tab.ATT 2tabs PO /OD  BBF-8am
3) Tab.thyonorm 50 mcg PO OD - 8AM
4) Tab ecospirin 75mg PO/OD
5) Syr.cremaffin plus 15 ml /Po H/S
6) Tab Benadon 40mg/PO/OD
7)Tab.Hifenac MR/PO/SOS
8) Tab.Pan 40 mg/PO/OD - 8AM
9) Tab.Ultracet 1/2 tab PO/SOS. 
10) Physiotherapy of neck
11) Air /water bed - position change 2nd hrly 
12)Neosporin powder for bed sore
13) Protein powder in glass of water or milk PO TID 
14) Egg whites 3 to 4 /day.
15)Tab wysolone 20 mg/PO/BD tapered within weeks

Advised attenders to get orthotic support.



On further follow up on 16/06/2023, 


    
 



 USG ABDOMEN - No sonological abnormality detected






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