A 65 year old male with Compressive myelopathy(c5-c6);?SOL in right para vertebral region (D1-D5)and ?D11-L1? Hansen's disease under evaluation with pre renal AKI.
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chest x-ray:
A 65 year old male, resident of Penpamad , came to casualty with c/o sudden onset of Unable to get up from the bed, unable to roll over, lift head above the pillow since 10days associated with pain in movements of the neck, radiating to B/L upper limbs right >left upto hand
Patient was apparently asymptomatic 10days back when he had burning micturition for 2- 3days not associated with fever but had generalised feeling of weakness for which he was treated outside with oral medications, followed by pain in the neck radiating to B/L hands right > left , pain while raising both legs which decreased upto the now presentation, associated with decreased sensations in B/L upper limb right >left.
Patient was confined to the bed for 3-4 days, not associated with giddiness, sweating, palpitation
Patient had increased intensity of pain when he tried to raise head above the pillow, get up from sitting position.
He is able to sense Bowel and bladder,
No band like sensation
No h/o fever
Patient had a h/o thorn pricking to left 2nd toe followed by blackish discoloration 10 days back.
Not a k/c/o diabetes mellitus, hypertension, CKD, CVA
H/o similar complaints of burning micturition 2 months back and diagnosed as ?Renal failure not on medication
On examination
Patient conscious, coherent, cooperative
Pallor present
No icterus, cyanosis, clubbing, lymphadenopathy
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Vitals
Temp - afebrile
BP - 120/80 mmhg
PR - 88 bpm
RR - 18 cpm
SpO2 - 99 at RA
CVS - S1 S2 heard
RS - BAE present, NVBS heard
Per Abdomen- soft, non tender
CNS -
GCS - 15/15
Patient is conscious and alert
Speech is normal
Neck stiffness is present with painful movement of head and raising both upper limbs
Cranial nerves - normal
Sensory system - decreased on right upper limb from C5 to C7 ( shoulder upto palm )
Motor system - Tone normal
Reflexes
Right Left
Biceps Couldn't elicit 3+
Triceps 2+ 3+
Supinator - 1+
Knee 2+ 2+
Ankle - -
Plantar Withdrawal
Muscles power:
Right Left
Upper limb
Elbow - Flexor 5/5 5/5
- extensor 5/5 5/5
Wrist - Flexor 5/5 5/5
- extensor 5/5 5/5
Hand grip 4/5 4/5
Lower limb
SLRT 70⁰ 40⁰
Hip - Flexors 5/5 5/5
- extensors 5/5 5/5
Knee - Flexors 5/5 5/5
- Extensors 5/5 5/5
Ankle - DF 4/5 4/5
- PF 4/5 4/5
EHL 3/5 3/5
FHL 3/5 3/5
Sensation ++ ++
Provisional diagnosis:
Compressive myelopathy secondary to prevertebral access/ soft tissue D1 - D3 ? Space occupying lesion D11 - L1 with mild C5 - C6 cord compression
Investigations:
ECG:
MRI REPORT:
Hemogram
Hb - 9.9
TLC - 14000
RBC - 3.94
Platelet count - 6 lakh
PCV - 31.2
CUE
Albumin- trace
Sugar - nil
Pus cells - 2 - 3
Epithelial cells - 2- 3
Red cells - nil
LFT
TB - 1.7
DB - 0.5
AST - 36
ALT - 49
ALP - 582
TP - 7.6
Albumin - 2.4
RBS - 80
RFT
Urea - 168
Creatinine - 3.5
Sr. Na - 133
Sr. K - 6
Sr. Cl - 90
Serology - negative
Treatment given on 18 th September:
IVF:1ns. With 1amp optineuron
T.pan 40mg/po/od
T.ultraset/po/tid
Soft collar
NBM till further orders to plan for contrast MRI.
T.MVT po/od
Nebulization with salbutamol 4th hourly
Treatment given on 19th September:
IVF:1ns. With 1amp optineuron
T.pan 40mg/po/od
T.ultraset/po/tid
Soft collar
T.MVT po/od
Nebulization with salbutamol 4th hourly
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