short case 2

A 57 year oldfemale patient came with complaints of weakness of both lower limbs Since 3 months.
Reduced sensations in both lower limbs since 3 month.
   
Patient was apparently asymptomatic 3 months back when she was doing her routine daily work, she developed weakness of left limb in the form she had difficulty in raising the left leg, she also had difficulty in climbing up and down stairs, difficulty in getting up from squatting position. 
But she was able to walk with difficulty
5 days later she noticed difficulty in gripping chappals and to walk with chappals in both lower limbs .
10 days later she Noticed similar weakness in right leg also .
Both her upper limbs were normal, She was able to lift her head from pillow, 
7 days later she developed numbness and burning sensations below the nipple area, and both lower limbs.
She had difficulty in feeling her clothes and had difficulty in differentiating hot and cold water below the nipple area.
No H/0 of improvement of weakness as the day progress .
H/0 of low backache insidious in onset dull aching pain diffusely felt around lumbosacral area,  gradually progessive in nature, non radiating since last one month, pain worsening with movement and recieving  pain killers,, 
Walking difficulty was not increasing in dark.
No H/0 of involuntary movements
No H/0 of altered sensorium, No H/0 of disorientation.
No H/0 of double vision
No H/0 of reduced sensations over face and she was able to chew food.
She was able to percieve the smell normally.
She was able to Close the eyes and no history of deviation of angle of mouth or drooling of saliva.

she was able to hear properly,no vertigo.
No H/0 of dysphagia , nasal regurgitation.

No H/0 of dysarhria.

She was able to feel the bladder sensation, initiate micturation and evaquate bladder completely, no history of post voidal urine sensation or post voidal dribbling.

No H /0 of bowel incontinence or constipation.

No H/0 of altered sweating pattern.

No H/0 of fever, headache, seizures, weight loss, skin rashes, and recent vaccination.

She was admitted in local hospital and got treatment but no improvement.

Past history:
she had a h/o thyroid surgery 4 years back.
No h/o hypertension,diabetes mellitus,CAD,asthma

Personal history: 
      diet is mixed
      Appetite is regular
      Bowel and bladder are regular
      Sleep adequate
      No addictions

No significant family history .

Summary : 

A 57 year old Female patient with no comorbities and no trauma history presented with subacute to chronic paraplegia started asymmetrically associated with no cranial nerve or autonomic involvement.

GENERAL EXAMINATION:

Patient is c/c/c and oriented.

Thin built and moderately nourished

Temperature:afebrile
Pallor-absent
Icterus-absent
No cyanosis,clubbing and lymphadenopathy

Bp:90/60mmhg
PR:75 bpm regular in rhythum and character , no radio femoral delay.
CVS:    S1 and S2 heard,no murmurs
RS:      BAE present NVBS.

P/A:soft and nontender,bowel sounds heard.

CNS EXAMINATION: 

CNS EXAMINATION:
 Speech is normal
Cranial nerves examination:normal

Motor examination
             

TONE
UL                    N.                       N
LL.                 Decreased       Decreased.

POWER
UL.                   5/5.                           5/5
LL.                   1/5                             1/5

REFLEXES
Superficial reflexes
Corneal         Present.             Present
Conjuctival   Present.             Present
Abdominal      upper              absent 
                         Lower             absent
Beevors sign - negative. 
Deep tendon reflexes
Biceps            present                 present
Triceps           present                 present
Supinator.      Present                 present
Knee.            Exaggerated      diminished  
Ankle.           Exaggerated      diminished      
Plantar.         Extensor             extensor.           

Sensory system examination- 

  pain, temp, vibration, joint position, and fine touch - bilaterally reduced below the level of nipples.

Cerebellar signs are normal .
Gait could not be assessed.
No neck rigidity
No signs of meningeal irritation
Spine - 
 tenderness felt at T6- L3 spine.
No Gibbus
No Kyphosis or scolios.

Provisional diagnosis- 
Extra medullary compressive myelopathy
Cadua equina syndrome.
Motor level - T6
Sensory level- T6
REFLEX LEVEL - T6.
Propable etiology - Metastasis.

Investigations 

CBP - 

HB - 12.0

TLC - 6000

PLT - 2.4 lakhs

CUE -  
Albumin- trace
Sugar- nil
Rbcs- nil
Pus cells - 4-5

RBS- 116 mg/ dl 

RFT -
Blood urea - 28 mg/ dl
Serum creatinine - 0.8 mg/dl
Sodium - 136 meq/l
Potassium - 3.9meq/l

ECG - 



MRI SPINE: 









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