CASE DISCUSSION 2 : Case of a 23 yr old male patient with bilateral Lower limb weakness

May 22, 2020

CASE DISCUSSION 2 : Case of a 23 yr old male patient with bilateral Lower limb weakness

K.mounika

Roll no 86

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

https://86kethavathmounika.blogspot.com/2020/05/case-of-23-yr-old-male-patient-with.html?m=1

My analysis of the patient is as follows:-

CHIEF COMPLAINTS IN PRIORITY ARE:-

* Bilateral lower limb weakness associated with tingling & numbness since 5days

*There is a history of sudden fall

*H/O vomiting - non projectile,non bilious

1.BILATERAL LOWER LIMB WEAKNESS

Possible points to be taken in to account while ruling out paraplegia:-

1. Onset whether acute/sub acute /chronic should be ruled out,as it helps to rule out etiology and furthur easy diagnosis.

2.H/O back ache& girdle pain

3. H/O wasting of muscles,fasciculations,tone,pattern of weakness,deep tendon reflexes,plantar response should be ruled out to know whether paraplegia is due to upper motor or lower motor neuron lesions

4. H/O fever ,cough ,expectoration

5.H/O involuntary movements

6.H/O seizures/syncope/altered sensorium/loss of consciousness

7.H/O bladder & bowel involvement, raised ICT

Propable causes are:-

*Trauma - in the given case it is ruled out there is no history of trauma

*Infections like - tuberculosis(potts disease or viral - as it ruled that there is no history of such infections)

*cerebellar disorder - it is ruled as there is no features like ataxia,nystagmus,seizures,incordination,no swaying while walking/inability to sit upright

*metabolic - vitamin B12 deficiency -as there is no pallor it is ruled out

Conditions to be ruled & investigated are:-

*Spinal cord injury - it is suggestive if there is sensory loss,spinal tract cross findings(pyramidal on one side and contralateral on spinothalamic), root plus long tract signs(spondylosis,sarcoidosis),urinary retention ,numbness.

*Tumors -like meningioma,lymphoma,glioma ruled out on MRI brain scans.Lumbar puncture,ICP monitoring,CSF analysis

*Transverse myelitis - weakness of limbs,sensory alterations,bowel & bladder dysfunction ruled out,investigation of csf reveal csf pleocytosis,ig G index & gadolinium enhancement

*vascular nd other demyelinating disorders should be ruled out

2.VOMITING

Possible causes:

*Brain tumors causing raised intracranial pressure eventually to vomiting

*Infections or may be due to drug toxicity

PAST HISTORY:-

-H/O sexual exposure

-Operated for gluteal abscess 5months back & scrotal abscess since 20 days

GENERAL EXAMINATION:-

- Patient is conscious,coherent cooperative

- vitals with in normal limits,afebrile

- no pallor,cyanosis,clubbing,icterus,koilonychia,lymphadenopathy

cvs: s1,s2 heard ,no added sounds

Respiratory: bilateral air entry,normal broncho vesicular breath sounds

*HIGHER MENTAL FUNCTIONS - speech,memory normal

*CNS - intact

MOTOR SYSTEM

Right. Left

Bulk: normal. Normal

Tone:

ul. normal. Normal

LL. . hypotonia . hypotonia

Power

ul. 5/5. 5/5

LL. 2/5. 0/5

Reflexes.

Superficial reflexes

Corneal,Conjunctival,abdominal - present on both sides

Plantar - extensor on both right & left side

Deep tendon reflexes

Right Left

Biceps. 2+ 1+

Triceps. 2+ 1+

Supinator. 3+ 2+

Knee. 3+ 2+

Ankle. 3+ 2+

jaw jerk. 1+ 1+

ankle

Clonus. present absent

Primitive reflex -absent

Involuntary movements - absent

SENSORY SYSTEM - normal

MENINGIAL SIGNS

Neck stiffness - negative

Kernigns sign - negative

Brudzinkis sign - negative

*Investigations:

* As there is a history of sexual exposure : HIV test is done which is - negative,

It is found that

There is significant enhancement which represents meningeal enhancement or exudates and following lesions in mri with multiple nodules in pulmonary apices suggest of pulmonary kochs and disseminated tuberculosis.

So the patient is now found to have Tuberculosis but didn't have any classical findings of TB.He should be evaluated for potts disease of spine

TREATMENT :

T.ATT 3 tabs/day fdc

T.Benadon 40mg/od

T.pregabalin 75mg/po/h/s

OINT.MEGAHEAL FOR LOCAL APPLICATION

SITZ BATH WITH BETADINE TID

FREQUENT CHANGE OF POSITION

MY DIAGNOSIS FOR THIS CASE IS:-

** Lumbar infective spondylodicitis & spondylitis due to TB(potts disease of spine is to be ruled yet)

Recommended investigation : MRI should be done to rule out TB spine(potts disease)

1.POSSIBLE ANATOMICAL LOCATION INVOLVED MAY BE:-

*Vertebrae(LUMBAR)

*DISCS OF spinal coloumn

2.PHYSIOLOGICAL FUNCTIONAL DISABILITY

*bilateral lower limb weakness

3.PATOLOGY IN THIS CASE MAY BE DUE TO:-

*Any injury to spinal column due to infections may cause the bones around the spinal cord to break & press against the spinal cord causing damage to nerves i.e leading to limb weakness

* As investigation showed pulmory foci & disseminated TB it can be a cause for b/l LL weakness