34 yr with COMPRESSIVE MYELOPATHY

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



Chief compliants
34 yr old male ,autodriver by occupation presented with c/o weakness of left lower limb since 7months 
Decreased sensations of left lower limb since 3 months
Tingling sensations of left foot since 2 months 

HOPI
Pt was apparently asymptomatic 7 months back then he noticed weakness in his left lower limbsb insidious onset , gradually progressive associated with decreased sensations since past 3 months and tingling sensation of left foot since 2 months 
He went to neurosurgeon on 24/8/2022 and was advised MRI dorsal spine which was normal .pt complaints did not resolve and he came to our hospital now
H/o difficulty in gripping his foot wear 
H/o difficulty in getting up from squatting position 
H/o difficulty in climbing upstairs and downstairs 
No H/o involuntary movements
H/o head trauma 10 yrs back (not associated with loss of consciousness , vomiting)
NoH/o LOC, memory loss,loss of smell, decreased vision, difficulty in chewing , deviation of mouth , dribbling of saliva
No H/o diplopia ,loss of hearing,hoarseness of voice 
NoH/o deviation of tongue 

H/o swagging positive 
No H/o bowel and bladder incontinence
NoH/o fever, vomiting ,headache 

Detailed history:
In JULY 2022 ,i.e.., 7 months ago - he developed weakness of left lower limb ,which was insidious in onset ,gradually progressive ,then he went to govt hospital at their native place and took medication .
inspite of taking medication , his weekness was not relieved and then , he went to Private hospital In August2022 ,where On investigations- his MRI was Normal and used medication .

He took complete rest for one month by staying at home i.ee in September 2022 but his weekness was not relieved on taking rest and medication.

 He Continued his work ,as Auto driver and farmer simultaneously despite of weekness of his left LL ,and he was not on medication .

In OCT 2022 ,i e..,3 months ago ,he developed tingling sensations of Left LL 
In NOV 2022, he developed decreased sensations in the left LL,and in the right LL ,where he took ayurvedic treatment but not relieved .
On Feb 4th 2023 ,i.e...,4 days ago, He came to our hospital - for further management .

There is H/O difficulty in getting up from Squatting position .
H/O increased tingling sensations on walking .
H/O head trauma ,10years ago - Pain associated with trauma ,relieved on taking medication .
Not associated with LOC, Vomitings ,bleeding at trauma site and ENT bleed .
No H/O fever ,recent trauma , speech abnormalities ,involuntary movements , irregular bowel and bladder movements, deviation of mouth and diplopia , burning micturition .


Past history
Not a know n case of epilepsy ,HTN ,T2DM ,CAD,CVA,ASTHMA, THYROID DISORDERs

Psycho -Social Component : 
34year Old Male ,who discontinued his education from 8th Class ,as his father got expired at the age of 12years ,He worked as daily wage labourer , in Construction site at Kerala for 5 years .
Where ,his Mother and Siblings stayed at their native place .
He lost his Mother at the age of 15 years .
He returned to his native place from kerala ,after death of his mother and started working as Auto driver and farmer simultaneously.
He has 2 siblings - Elder brother - His age is 40yrs now - he has 5 Children - 4 Girls and 1 Boy
Elder sister - Her age is 38years now -She has 2 children .
He got married at the age of 22years - His wife is supportive and caring women .
His 1st Child was Son - Expired at the age of 1 year - after 3months of hospital stay .
He has 3 year Old female child now .
His agricultural land and own house was given by his father , where his Brother and himself shared their land and started farming .There are small disputes in their family regarding land .
He is Occasional alcoholic, Consumes tobbacco.
During Conversation, Eye to eye contact maintained and PMA -Normal .

Personal history
DIET:mixed
Appetite: Normal
Bowel and bladder movements are regular
Sleep: adequate 
No allergies
Occasional alcoholic 

General examination
Pt is conscious , incoherent, co-operative
No  pallor,Icterus,Cyanosis,Clubbing,Edema and lymphadenopathy
Vitals
 BP -110/70mmhg
 PR -76 BPM
 RR -18 cpm
 Spo2 -98
Grbs:108 mg/ dl
Systemic examination -
Respiratory examination:
BAE + and normal vesicular breath sounds heard 
 No crepts heard 
CVS examination:
 S1S2 heard 
 No murmurs heard
 Abdomen examination:
 Soft non tender
 No hepatomegaly and splenomegaly

CENTRAL NERVOUS SYSTEM EXAMINATION- 
Higher mental functions
- Conscious
- Oriented to time,place and person
- Memory - Intact
- Speech - no deficit

Cranial nerve examination 
1 - olfactory sense - normal
2- Direct and indirect light reflex present
3,4,6 - no ptosis and nystagmus
All eye movements were normal
5- Touch - 
Sensory -by cotton and pin felt
 Motor - chewing movements seen             
7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present
8- Hearing normal 
9,10- position of uvula is central
No regurgitation after drinking water
11- looked for trapezius muscle - contraction present
12- no deviation of tongue on protrusion
Motor system 
Attitude - left and right lower limb slightly flexed at knee joint in lying down posture
Reflexes 
                          Right   Left            
Biceps               -               -
Triceps              -               -
Supinator           -               -
 Knee. .              +3            +2
Ankle.                +2.          +2
Babinski            B/L extension    

Power
Upper limb -5/5
Lower limb -5/5         
                                
TONE            Lt. Rt
 Upper limbs N N                
 Lower limbs N N                 
No involuntary movements
SENSORY SYSTEM
I – SPINOTHALAMIC R L
1. Crude touch N N 
2. Pain. N. N
II – POSTERIOR COLUMN
1. Fine touch. N. N
2. Vibration sense not felt on Lt lower limb but it slightly felt on rt lower limb             
3. Position sense. N. N
4. Romberg’s sign - positive
III – CORTICAL
1. Two point 
    discrimination.               
2. Tactile localisation. Not localised at some points and he delayed to localise the point at other regions in both lower limbs 
3. Graphaesthesia. N. N
4. Stereognosis. N. N
Finger nose Coordination present 
No dysdiadokinesia 
Knee heel coordination present 
Gait. Appear to be normal 
         Swaying seen when he walks on narrow path
And discomfort seen while walking down stairs

Provisional diagnosis 
C5- C6 compressive MYELOPATHY 

Investigation
Electrolytes
Na 139
K.  4.2
Cl. 104
Blood urea  26
S creatinine  0.9

RBS 95
FBS 87
Hba1c 6.5%

Hemogram 
Hb 10.6
TLC 8200
PLT 2.27
CUE
Albumin and sugar nil 
Serology 
Negative 

2d echo
EF 62%
TRIVIAL TR+,AR+ , No MR
No RWMA ,No As/MS 
Good Lv systolic function 
No diastolic dysfunction ,no pah.
Ecg 
MRI cervical  spine  with whole spine screening:
C3-C4,C4-C5,C6-C7 disc degeneration 
C5-C6 disc osteophyte complex causing mederate cord compression with cord edema /early myelomalacia




Treatment given:
Optineuron 1 amp in 100 ml NS IV/OD
Tab Neurobion po od 
Tab Amytriptyline 10mg po hs

Definitive treatment 
Pt needs anterior cervical  decompression and fusion

COURSE IN THE HOSPITAL-

HE WAS ADVISED FOR MRI CERVICAL SPINE WITH WHOLE SPINE SCREENING-

IMPRESSION- C5-C6 DISC OSTEOPHYTE COMPLEX CAUSING MODERATE CORD COMPRESSION WITH CORD EDEMA/EARLY MYELOMALACIA

 NEUROSURGERY OPINION WAS TAKEN ON 6/2/23 IN VIEW OF C5-C6 COMPRESSION MYELOPATHY AND WAS ADVISED FOR ANTERIOR CERVICAL DECOMPRESSION AND FUSION
DERMATOLOGY OPINION WAS TAKEN ON 14/2/23 I/V/O ITCHY SKIN LESIONS OVER B/L PLAMS- DORSUM AND PALMAR ASPECT SINCE 15 DAYS
DIAGNOSED AS ALLERGIC CONTACT DERMATITIS

ADVISED-
FUDIC CREAM L/A BD
CEBHYDRA LOTION L/A BD
TAB. TECZINE 5 MG SOS OD


Advise at discharge:
T. NEUROBION PO/OD
TAB. AMITRIPTYLINE 10 MG PO/HS
FUDIC CREAM L/A BD FOR 2 WEEKS
T. CEBHYDRA LOTION L/A BD X 2 WEEKS
T.TECZINE 5 MG PO/ SOS
SOFT CERVICAL COLLAR

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