65 YEAR OLD MALE WITH QUADRIPARESIS

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20-09-2021

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CASE: 

A 65 year old male, came to casualty with chief complaints that he was unable to get up from the bed, unable to roll over, lift head above the pillow which was sudden in onset 17 days ago associated with pain in movements of the neck, radiating to B/L upper limbs and generalised body pains

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 17 days back when he had burning micturition for 2- 3days not associated with fever but had generalised feeling of weakness for which he was treated outside with oral medications, followed by pain in the neck radiating to B/L hands right > left , pain while raising both legs which decreased upto the now presentation, associated with decreased sensations in B/L upper limb right >left.

Patient was confined to the bed for 3-4 days, not associated with giddiness, sweating, palpitation 

Patient had increased intensity of pain when he tried to raise head above the pillow, get up from sitting position.

He is able to sense Bowel and bladder, 

No band like sensation 

No h/o fever 

PAST HISTORY:

Not a k/c/o diabetes mellitus, hypertension, CKD, CVA 

30 years ago he had hyperpigmentation on his skin for which a biopsy was taken but the results cannot be recalled by the patient 

H/o similar complaints of burning micturition 2 months back and diagnosed as Renal failure in another medical facility he’s not on medication.

Patient had a h/o thorn pricking to left 2nd toe followed by blackish discoloration 17 days back.

GENERAL EXAMINATION:

On examination 

Patient conscious, coherent, cooperative 

Pallor present

No icterus, cyanosis, clubbing, lymphadenopathy 

VITALS:

Temp - afebrile 

BP - 120/80 mmhg 

PR - 88 bpm 

RR - 18 cpm 

SpO2 - 99 at RA 

CVS - S1 S2 heard 

RS - BAE present, NVBS heard 

Per Abdomen- soft, non tender 

CNS - 

GCS - 15/15

Patient is conscious and alert

Speech is normal 

Neck stiffness is present with painful movement of head and raising both upper limbs 

Cranial nerves - normal 

Sensory system - decreased on right upper limb from C5 to C7 ( shoulder upto palm )

Motor system - Tone normal 

  Reflexes 

                          Right             Left 

Biceps       Couldn't elicit          3+

Triceps               2+                  3+

Supinator            -                    1+ 

Knee                  2+                  2+ 

Ankle                  -                       - 

Plantar                  Withdrawal 

Muscles power: 

                                       Right            Left 

Upper limb 

Elbow - Flexor                5/5             5/5 

            - extensor           5/5             5/5 

Wrist - Flexor                 5/5              5/5

          - extensor            5/5              5/5 

Hand grip                      4/5              4/5 

Lower limb

SLRT                               70⁰               40⁰

Hip  - Flexors                  5/5              5/5 

      - extensors                5/5              5/5

Knee - Flexors                5/5              5/5

          - Extensors           5/5              5/5

Ankle - DF                       4/5              4/5

           - PF                       4/5               4/5

EHL                                  3/5               3/5 

FHL                                  3/5               3/5

Sensation                        ++                 ++ 

Provisional diagnosis:

Compressive myelopathy secondary to prevertebral access/ soft tissue D1 - D3 ? Space occupying lesion D11 - L1 with mild C5 - C6 cord compression 

INVESTIGATION:

Hemogram 

Hb - 9.9

TLC - 14000

RBC - 3.94

Platelet count - 6 lakh 

PCV - 31.2 

CUE 

Albumin- trace 

Sugar - nil 

Pus cells - 2 - 3 

Epithelial cells - 2- 3 

Red cells - nil 

LFT 

TB - 1.7 

DB - 0.5

AST - 36

ALT - 49

ALP - 582

TP - 7.6

Albumin - 2.4 

RBS - 80 

RFT 

Urea - 168

Creatinine - 3.5

Sr. Na - 133

Sr. K - 6

Sr. Cl - 90

Serology - negative 

ECG:

XRAY:

MRI: