A 50 YEAR OLD PATIENT WITH CERVICAL 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.

A 50 YEAR OLD MALE WITH CERVICAL MYELOPATHY 

Following is the view of my case(history as per date of admission)

CASE:

50-year-old male patient presented to hospital with complaints of weakness of all four limbs since 8 PM yesterday.

HISTORY OF PRESENTING ILLNESS:

-Patient was apparently a symptomatic before 8 PM yesterday then he developed weakness of all four limbs which was sudden in onset and preceded by history of Alcohol binge and fall.

-No H/o slurring of speech

-No H/o fever

HISTORY OF PAST ILLNESS:

-History of hypertension since five years, patient is on regular medication

-No H/o of loss of consciousness 

-No H/o of DM,Epilepsy,TB

-No similar complaints in past

-No H/o past surgery 

PERSONAL HISTORY:

Diet- mixed

Appetite-normal 

Sleep-adequate 

Bowel and bladder movements-regular 

Addictions-drinks occasionally(90 ml everyday)

FAMILY HISTORY 

no history of DM,HNT,heart diseases,stroke

GENERAL EXAMINATION:

The patient was conscious,coherent and cooperative and well oriented to time place and person.He is sitting comfortably on the bed ,moderately build and well nourished.

Pallor-absent 

Icterus-absent

Clubbing-absent

Cyanosis-absent

Lymphadenopathy-absent

Edema - absent

VITALS-

Temperature -98.6^C

Pulse rate-72/min

Respiratory rate-18/min

BP-140/90mm of Hg

GRBS-131mg%

SYSTEMIC EXAMINATIONS:

CVS-S1 and S2 heard,no added mummers and thrills heard

                                                                       ECG

RESPIRATORY SYSTEM-normal vesicular breath sounds heard

ABDOMEN-soft and non tender,no organomegaly

CNS

- no sensory symptoms are present

-motor system examination 

                                 LEFT                                                                       RIGHT

POWER

upper limb                1/5                                                                            1/5

Lower limb               0/5                                                                            0/5

REFLEXES 

biceps                     Absent                                                                      Absent 

Triceps                   Absent                                                                      Absent 

Knee                      Absent                                                                      Absent 

Ankle                    Absent                                                                      Absent 

CRANIAL NERVES- normal 

GLASGOW SCALE-15/15

INVESTIGATIONS

                   HEMOGRAM

-PCV: 38.9(decreased )

-RBC count: 4.25(decreased)

-SMEAR :normocytic normochromic

       

               COMPLETE BLOOD PICTURE 

                LIVER FUNCTION TEST

-alkaline phosphate : 167IU/L(increased)

-total proteins : 6.2gm/dl (decreased)

               SMEAR URIC ACID

               BLOOD UREA

               SMEAR CHLORIDE 

               APTT

               PROTHROMBIN TIME

               CK

RADIOLOGICAL FINDINGS

PROVISIONAL DIAGNOSIS 

-C3-C6 OPLL that is osteomalacial changes referred for neurosurgical intervention 

-quadriparesis

-hypokalemia 

TREATMENT 

 - INJ.OPTINEURON 1AMP IN 100 ML NS IV/OD

-IN THIAMINE 1 AMP IN 100 NS/IV/TID

-TAB DEXAMETHASONE 8MG BD

-GBRS CHARTING 6TH HOURLY 4.TAB.DOLO 650 MG/PO/TID

- Ortho referal and referred to higher center as per orthopaedicians advice.

ADVICE AT DISCHARGE 

-Patient being referred to higher Centre I/V/O NEUROSURGICAL INTERVENTION 

-SURGERY ADVISED: C3-C6 screw fixation,C3-C6 lamenectomy