Compressive myelopathy

J. Akash

4th year

                    

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

Your valuable inputs on comment box is welcome

 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan                     

A 65 year old male patient, farmer by occupation, resident of suryapet has come to the casualty with the chief complaints of


1) Generalised body weakness since 10 days


HOPI


The patient was apparently asymptotic 2 months back


He developed burning micturition one day after which when he was taken to local hospital, found out to be with Kidney problem AKI? He was given oral medicines for 1 week and was sent to home


The same complaint started again after 11/2 month.This time he was given IV medications and sent home after 4 days.


10 days back, he started having generalised weakness which was gradual in onset associated with generalised pain which was of prickling type, neck pain which exacerbated when he tried to get up from supine position.


He also complained of tingling sensation of soles and left wrist pain which was due to a trauma caused by pull.


PAST HISTORY 


He had a bee bite 30 years back. Treated with medications 


He also had thorn prick 10 days back following which his lower limbs had pigmentation.


PERSONAL HISTORY 


Diet- mixed(vegetarian since 2 months)


Appetite- normal


Sleep- adequate 


Bowel and bladder movements- regular


Sleep- adequate 


Addictions- chutta(2-3 months back) occasional


Occasional drink( once per month)


FAMILY HISTORY 


Not significant 


GENERAL EXAMINATION 


The patient was coherent conscious cooperative well oriented to time place and person 


He was poorly built and nourished  with muscle wasting 

Right foot


Right hand



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                        ++                 ++


Investigations:





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


Provisional diagnosis:

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



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