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
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| | | |
| i) Visual acuity – Snellen Chart ii) Colour vision – Ishihara chart iii) Fundus | | |
| 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 |
| 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 |
| 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 |
| i) Rinnes Test ii) Webers Test iii) Nystagmus | Positive Not lateralised Absent | |
| i) Uvula, Palatal arches, and movements ii) Gag reflex iii) Palatal reflex | Centrally placed and symmetrical Present Present | |
| i) trapezius ii) sternocleidomastoid | | |
| i) Tone ii) Wasting iii) Fibrillation iv) Tongue Protrusion to the midline and either side | | |
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
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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
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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