36Y Male suffering from Quadriplegia

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

This is the case of a 36-year-old male, resident of West Bengal, and Fish seller by occupation. The following history was taken with the patient in person. The patient was explained about confidentiality and written consent was taken to create the following case report.

This case report aims to record the patient's journey.

CHIEF COMPLAINTS:-

- THE PATIENT MET WITH AN ACCIDENT ON 7.03.23 (HOLI)

- WEAKNESS IN BILATERAL UPPER AND LOWER LIMBS SINCE 3 MONTHS

- RETENTION OF URINE SINCE 3 MONTHS

-DECREASED SENSATION ON LOWER LIMBS - 3 MONTHS

History of present illness:-

The patient was apparently asymptomatic 3 months back then he met an RTA skid and fall from 2 wheeler on 7.03.23 (Holi) around 9:00pm. As soon as the accident happened, he got unconscious and was taken to a local hospital, where it was said that he injured his back. According to the patient, he was unconscious for a whole day. After regaining conciousness, the patient was unable to move both of his legs, was able to partially flex his elbow to a certain extent. The patient was unable to clench his fists completely on both sides, with the left hand having more power than the right. There was pain on both of the wrists, radiating to all of the fingers and being throbbing in type, and continuous in nature. However currently, the progression of the intensity of the pain is decreasing and the patient is able to clench his fists on both sides to some extent.

The patient also mentions experiencing hip pain due to the injury he has sustained when he was in the hospital. This pain lasted for two to three days, and disappeared after that.

On 10.03.23, the patient was admitted to another hospital where the following investigations were done:-

1) NCCT of the brain was done. it has ruled out the presence of any head injury.

2) MRI OF SPINE spine was done, which suggested disc bulges (lesions) at L4-L5, L5-S1 and C3-C4, C4-C5.

The Patient was later advised to undergo physiotherapy.

Upon admission to the OPD, the patient presented with the following symptoms:-

1) the patient was unable to use both the lower limbs voluntarily. The severity of the condition is a paresis and the progression of the condition is static and chronic. He was not able to sit initially after the accident but now he can sit on his own without an attendant.

2) Slight neck pain felt when patient is lifting his head. Pain is described as throbbing type, and aggrevated when the patient is lifting his head.

3) he also complained of tightness around the abdomen (Band like sensation/girdle like sensation)

4) The patient also complained of retention of urine able to feel the fullness of the bladder but is unable to initiate micturition for which a catheter is inserted since 2 months.

Other observations include:-

1) The patient was unable to comb the hair since the time of the accident, but he able to take the food to the mouth by himself.

2) The patient was unable to button the shirt by himself since the time of the accident.

3) The patient was able to squat and getting up from the squatting position with help, but he cannot climbing stairs up and down or walk by himself.

4) The patient cannot perform slipping of chappals, and there is no tripping of toe.

5) The patient with help, can roll over the bed, and get up from the bed.

6)No Difficulty in breathing.

7) There is no diurnal variation of weakness.

Negative history

No h/o visual disturbances, headache, diplopia, ptosis he is able to appreciate smell, hes able to look towards all sides no h/o sensory loss over the face, no facial deviation.

No noted sensory deficit as the patient was able to feel clothes, feeling hot and cold water while bathing.

No h/o auditory disturbances

No h/o restricted tongue movements

No difficulty in swallowing

No difficulty in speaking

No h/o abnormal sweating

No h/o shooting pain

No h/o headache or vomiting.

No h/o seizures

No h/o Fasciculations/muscle twitchings.

No h/o Involuntary movements like chorea, athetosis, tremors, hemiballismus

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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 :

Alcohol consumption since 8 yrs (2 quarters daily )

Tobacco chewing since 6 yrs

FAMILY HISTORY :

Not significant

GENERAL EXAMINATION

Pt is conscious, coherent, cooperative moderately 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

The 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

CNS EXAMINATION:-

Bulk

rt lf

Arm 23 cm 23cm

Forearm 24cm 24cm

Leg 29cm 29cm

Tone

rt lf

Arm increased increased

Leg increased increased

Power

rt lf

Deltoid 5 5

Supraspinatus 5 5

Infraspinatus 5 5

Pectoralis major +4 +4

Biceps 5 5

Brachioradialis 5 5

Triceps -4 -4

ECR 5 5

ECU 5 5

Extensor digitorum -4 -4

FCU 3 -4

Abductor pollicis longus -4 +4

EPB -4 +4

Opponens pollicis -unable to do on both-

Abductor pollicis brevis 3 +4

Adductor policis -4 4

Lumbricals and interossei

Test one -4 -4

Test two 3 3

Lower limbs

Illeopsoas 3 -4

Adductor femoris -4 +4

Gluteus medius and minimus 5 5

Gluteus maximus 3 3

Hamstrings +4 -4

Quadriceps +4 +4

TA -4 +4

TP +4 +4

Peronius -4 +4

Gastrocnemius +4 +4

EHL +4 -4

Extensor digitorum longus 3 3

Flexor Digitorum Longus 5 +4

Reflexes :

SUPERFICIAL:

Plantar not visualized

Abdominal reflexes -mute

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

MENINGEAL SIGNS

neck stiffnesses. Absent

Kernigs sign - absent

Brudzinski sign - not visualised

MRI OF SPINE :

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

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