23YR OLD MALE WITH PARAPARESIS
ANKAM SATHYA KISHORE(07)
You can find the entire real patient clinical problem in this link here..
https://vaish7.blogspot.com/2020/05/medicine.html?m=1
Chief complaints and their explanation:
*weakness of bilateral lower limbs since 5 days
Onset:sudden in onset
Duration :since 5 days
Associated conditions :
- Tingling and numbness
- history of sudden fall while he got up
for urination.
CNS EXAMINATION:
Cns conscious
speech-normal
cranial nerves intact.
MOTOR SYSTEM
Right. Left
Bulk: normal. Normal
Tone: ul. normal. Normal
LL. hypotonia hypotonia
Power rt. lt
ul. 5/5. 5/5
LL. 2/5. 0/5
Reflexes.
Superficial reflexes
Right. Left
Corneal. P P
Conjunctival P. P
Abdominal. P. P
Plantar Extensor Extensor
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
CEREBELLUM
titubation - absent
Nystagmus- absent
Intensional tremors - absent
Pendular knee jerk - absent
Coordination test -normal
MENINGIAL SIGNS
Neck stiffness - negative
Kernigns sign - negative
Brudzinkis sign - negative
(Bilateral lower limb hypotonia,hyporeflexia and paraplegia characteristic of LMN LESION can be seen from above examination)
*Vomitings:
These are may be due to intracranial space occupying lesions which causes raised intracranial pressure and vomitings.
*Gluteal abcess:
Operated 5 months back
*Scrotal abcess:
Opeeated 10days back
These two abcess are cold abcess as there is no signs of inflammation.
Past history:
no similar complaints in past
h/o multiple sexual partners
auto driver( high risk behaviour)
not a known case of HTN/DM/ASTHMA/CAD
General examination:
Pallor absent
Icterus absent
No cyanosis clubbing lymphademopathy,Edema
Afebrile
Gluteal abscess post drainage
Bp 120/80 mm hg
Pr 80 bpm
spo2 98%
Cvs s1 s2 hears no murmurs
Rs bae + nvbs hears
P/a soft, non tender
INVESTIGATIONS:
HBS AG: negative
ANTIHCV ANTIBODIES: nonreactive
HIV : non reactive
HEMOGRAM :
HB 15.5gm/dl
Platelets 2.23 lakhs/cumm
TLC 9600cells/cumm
Lymphocytes 15%
LFT
TO.BIL. 0.82mg/dl
DI.BIL. 0.21gm/dl
SGOT. 80IU/LIT
SGPT. 10IU/LIT
ALK.PH. 192IU/LIT
TO.PRO. 7.5gm/dl
ALB. 4gm/dl
A/G RATIO. 1.19
RFT
UREA. 16mg/dl
CREATININE. 0.6mg/dl
URIC ACID 3.7mg/dl
CALCIUM. 9.4mg/dl
PHOS. 4.6mg/dl
SODIUM. 136meq/lit
K+. 3.9meq/lit
CL-. 102 meq/lit
ESR 45 mm/1st hr
RBS 99 mg/dl
Provisional Diagnosis from the case:
Paraparesis with L4,L5infective spondylodiscitis with left psoas abscess with ring enhancing lesions in right and left cerebral hemispheres with healing ulcer in right gluteal region secondary to drained gluteal abscess with pyocele left side operated ( 10 days back)
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 thoughts on this case:
*As The patient have multiple sexual partners it is
advised him to screen for HIV and RTPCR for
knowing any resistant strain of
Myocobacterium(as both HIV and TB are
commonly associated)
*Patient is having Dissiminated TB it may spread
and cause abscess at right gluteal region and
scrotal region
*Cold abscess formed may compress at L4 and
L5 causing Paraparesis
*DW-MRI ( diffusion weighted MRI ) is further preferred because it helps in location of acute infarcts,tumours in brain as the patient had a history of sudden onset of paraplegia which may be due to vascular cause like stroke.
*MR SPECTROSCOPY this confirms the tuberculoma by detecting increased levels of lipid lactate and cheesy material in brain
*CT scan is also preferred Which clearly shows any edema in the brain,that MRI couldn't appreciate