1801006035 LONG CASE 36 yr old male with UL AND LL WEAKNESS

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A 36 YR OLD MALE  FISH VENDOR BY OCCUPATION CAME TO OPD WITH 

CHEIF COMPLAINTS : 

Met with an accident on 7/03/23 ( HOLY ) 

- WEAKNESS IN  BILATERAL UPPER AND LOWER LIMB  - 3 months 

- RETENTION OF URINE - since 3MONTHS 

-DECREASED SENSATION ON LOWER LIMBS - 3MONTHS 

History of presenting illness : 

Patient was apparently asymptomatic 3 months back then while coming back to home after celebrating holy ,He took alcohol of 250ml before driving then he met with an accident,Where patient fell unconscious for a day during this time he was taken to local hospital ,where he was said that he got injured to his back and neck 

Later he developed Bilateral Upper and lower limb weakness which is sudden in onset and gradually progressive with no involvement of neck ,trunk , with no diurnal variation .unable to walk or stand 

And Decreased sensation in the lower limb  i.e decraeased ability to feel cold and hot water while bathing and Retention of urine  able to feel the fullness of bladder but unable to initiate micturation for which a catheter is inserted 

At the time of accident patient was unable to move his toe but later in the course of 1 and half month now he was able to move his legs and arms comparitively 

Patient also complaints  of pain in joints of upper limb i.e forearm and wrist since 1month and pain in the back since 1 month. 

H/O of loss of consciousness after the accident for 1day 

No H/O  of any speech disturbances 

No h/o of any blurring of vision 

No h/o of any involuntary movements 

No h /o weight loss 

No h/0 of any hearing problems 

PAST HISTORY : 

No h/O of similar complaints in the past 

H/O of Dizziness while waking up from bed  (Montly twice ) 

No H/O of DM ,HTN ,TB ,EPILEPSY 

Treatment HISTORY : 

No specific treatment 

PERSONAL HISTORY : 

MARITAL STATUS : Married 

DIET : Mixed 

APPETITE : NORMAL 

SLEEP : irregular and inadequate 

Bowel movements : irregular 

Bladder : Unable to pass urine since 3 months 

No history of any allergens 

Addictions : 

Alochol consumption since 8 yrs (2 quaters daily ) 

Tabacoo chewing since 6 yrs 

FAMILY HISTORY : 

Not siginficant 

GENERAL EXAMINATION 

Pt is consious ,coherent , co operative moderatly built and moderately nourished 

No H/O of 

Pallor 

Icterus 

cyanosis 

clubbing 

Lymphadenopathy 

Edema

VITALS : 

Temp :Afebrile 

PR : 86 bpm 

Rr :18 cycles /min 

BP : 130/80 mm of hg 

SYSTEMIC EXAMINATION : 

RESPIRATORY SYSTEM : 

Trachea Central 

NVBS 

No murmurs 

CVS 

S1 and s2 sounds heard

No cardiac murmurs

ABDOMINAL EXAMINATION : 

shape - scaphoid

Tenderness- no

Palpable mass - no

Liver - not palpable

Spleen - not palpable

Bowel sounds - normal 

NEUROLOGICAL EXAMINATION : 

Higher mental function 

Patient is conscious well oriented to time place and person 

No delusions or hallucinations 

Dominant right hand

CRANIAL NERVE EXAMINATION:

CN 1 : smell sense RIGHT       LEFT 

                                +.               + 

CN 2 : visual acuity normal     Normal 

CN 3 4  6 : extra ocular movement : full 

                   Direct light reflex present 

                   Consensual light reflex present 

                    Ptosis absent 

                     Accommodation reflex present 

CN 5 :        Sensory : over face ,buccal mucosa : normal 

                   Motor: masseter ,temporalis : normal 

                    Reflexes :corneal : normal

                                 Conjunctival : normal 

CN7 :     Motor : nasolabial fold : present 

            

                Reflexes: corneal conjunctival present 

 CN 8:    Rinnes  +

                Webers  not lateralised 

             Nystagmus : absent     

          

CN 9 and 10 : uulva movemts normal 

MOTOR SYSTEM : 

BULK: Inspection : Decreased 

             Palpation : Decreased 

MID ARM CIRCUMFERENCE : RIGHT     LEFT 

                                                        24cms     23cms 

TONE : hypertonic 

Power :                 Rt                Lft 

             UL          5/5              5/5 

             LL          4/5.             4/5 

Reflexes :

Superficial: 

 Plantar : not visualised 

Abdominal reflexes -absent 

                                 

DEEP TENDON REFLEXES :

                Rt      Lft 

Biceps :  + 3      +3 

Triceps:   +3      +3

Supinator : +3    +3 

Knee jerk : +3    +3 

Ankle jerk : +2    +2 

SENSORY SYSTEM : 

Posterior column:

 fine touch  - normal  

  Vibration  - normal 

SPINO THALAMIC : 

Pain : decreased sensation to pain in lower limbs 

Temperature: decreased sensation to heat and cold in lower limbs 

CEREBELLAR SIGNS : 

Finger nose test :  normal 

Heel knee test : unable to touch

MENINGIAL SIGNS 

neck stiffnesses.  Absent 

Kernigs sign - absent 

Brudzinski sign - not visualised 

Examination Videos : 

https://photos.app.goo.gl/7LbqNwX1GxSBvNvBA

MRI OF SPINE : 

Diffuse disc bulge are seen at L4-L5, L5-S1 levels, causing secondary spinal stenosis.

Diffuse disc bulges are seen at C3-C4,C4-C5 levels, causing secondary spinal canal stenosis with mild narrowing of bilateral neural foramina with mild impingement of bilateral exiting nerve roots. 

Provisional Diagnosis  : 

Traumatic Quadriparesis  ? 

Due to compression of spinal cord at L4 -L5 ,L5 -S1