65 YEAR OLD MALE WITH QUADRIPARESIS

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 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your 

valuable comments on comment box is welcome

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:






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