General medicine case 6

October 29, 2021

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

A 45 yeasr old female patient housewife by occupation presented to opd with weakness of lower limbs since 3 months and inability to walk since one and half month complaints of pain and inability to extend her right lower limb since one and half month

HISTORY Of PRESENT ILLNESS

Patient was apparently asymptomatic 18yrs back then she noticed a small swelling in the neck region and which gradually increased in size 3months ago.

She was having difficulty in positioning of her feet while walking and even had slippage of footwear.2 months ago she slipped and fell in bathroom and fractured her right ankle joint for which she received treatment from a local hospital .

1 month prior to admission patient lost her ability to walk and has been using wheelchair since then to get around.

Patient complaints of both upper and lower backpain radiating to her hip joints with stiffness of muscles of inner part of both thighs associated with dragging type of pain radiating along the inner part of thigh while stretching her lowerlimbs and more on the right side.

Patient also complained of inability to lie down in supine position as it caused pain in her lowerlimbs and cannot sit for a long time in the same position .

She is not able to extend her right lower limb completely and her lowerlimbs have become thinner as compared to 2 months ago. Patient also gave a history of constipation and passing bloody stools when straining to pass hard stools . And there is a history of recent weight loss of 2 kgs in last 2months with lowerlimbs becoming thinner than before.

PAST HISTORY

Patient has had similar complaints of both upper and lower backpain radiating to both hip joints since one and half year ago and has been using over the counter pain relief medication . Patient had gallstone removal surgery 6yrs ago.

PERSONAL HISTORY

Patient has normal appetite and takes mixed diet .

Bowel and bladder movements she has constipation. Inability to feel while passing urine and reduced quality of sleep for last 2 months due to pain.

Addictions: patient consumes 2 pans per day for past 6yrs

GENERAL PHYSICAL EXAMINATION

Patient is concious , coherent and cooperative and well oriented to time, place and person .

Pallor present

No icterus, cyanosis, clubbing, generalized lymphadenopathy

Vitals:

Temp - afebrile

Blood pressure- 100/70mmHg

PR- 78bpm

SPO2 - 99%at room air

GRBS- 110mg/dl

SYSTEMIC EXAMINATION

CVS :

Inspection- chest wall is bilaterally symmetrical

No precordial bulge

No visible pulsations , engorged veins , scars and sinuses

Palpation-

JVP normal

Apex beta felt in the left 5th intercoastal space in midclavicular line

Ascultation- S1 S2 heard

RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea is central

Normal vesicular breath sounds heard

No added sounds

PER ABDOMEN

Abdomen is soft and non tender

Bowel sounds heard

CNS EXAMINATION

Patients is concious , higher mental function are intact and speech is intact , signs of meningeal irritation is absent

Patient's attener gave a history of incidentally finding that patients response to warm temperature was delayed when they placed a cup of hot tea on her ankle .

Proprioception lost up to hip joint . On palpation stiffening of muscles of medial and posterior compartments of both thighs. No spine tenderness present .

Surgery opinion was taken for neck swelling . USG and FNAC of neck was advised .

Orthopedic advice was taken for secondary deposits in sacral and lumbar region with a pathological collapse in T12 seen in MRI .