A CASE OF POST TRAUMATIC QUADRIPLEGIA WITH LMN TYPE BLADDER PRESENTED IN SUMMER OF 2023
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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 a diagnosis and providing treatment best to our skills and wisdom.
A 36yr old patient who is a fish seller by profession presented to the casualty with complaints of loss of sensation and weakness in the lower limbs and retention of urine
Date of Admission: 11/06/23
CHIEF COMPLAINTS
➤ Weakness in B/L Upper and Lower limbs since 3 months .
➤ Retention of urine since 3 months .
➤ Decreased sensation of B/L lower limbs since 3 months .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 3 months ago . Then he met with a RTA (bike accident ) on 7/3/23 and sustained injuries to the back and the head . Since then the patient had B/L weakness of upper and lower limbs alongwith retention of urine.
Patient had h/o loss of consciousness since 1 day following the fall from the bike .
No h/o involuntary movements or vomitting.
HISTORY OF PAST ILLNESS
➤ Not a k/c/o diabetes mellitus, HTN , TB epilepsy , asthma ,CAD , thyroid disorders.
PERSONAL HISTORY
➤Occupation: Fish seller
➤Patient is married .
➤Patient takes a mixed diet and has a normal appetite.
➤Sleep : Regular
➤Bowel movements are normal , unable to pass urine since 3 months .
➤No known allergies .
➤ Addictions - Alcohol : 3-4 quarters/day since 6 yrs .
Pan
➤ No h/o surgery or blood transfusion.
FAMILY HISTORY
Not significant .
GENERAL EXAMINATION
➤Pallor : not seen
➤Icterus : not seen
➤Cyanosis : not seen
➤Clubbing : not seen
➤Lymphadenopathy : not seen
➤Edema : not seen .
VITALS
➤ Afebrile
➤PR : 88 beats per minute
➤BP : 100/70 mm Hg
➤RR : 18 cycles per minute
➤SpO2 : 96% in room air
➤ GRBS : 103 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent.,
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
➤Trachea is in midline.
➤ Breath sounds - vesicular
➤ Additional sounds - Rhonchi heard
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Scaphoid
➤Equal movements in all the quadrants.
➤No visible pulsation, dilated veins and localized swellings.
PALPATION
➤Liver , spleen not palpable.
➤ No tenderness .
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Conscious and coherent
➤Speech : Normal
➤No signs of meningeal irritation
➤ Cranial nerves intact .
➤ Motor system
Power Rt. Lt
U/L. 5/5 5/5
L/L. 4/5. 4/5
Tone
U/L. Hyper Hyper
L/L. Hyper Hyper
GCS - E4 V5 M6
Reflexes. B T. S. K. A. plantar
Lt: 3+. 3+. 3+. 4+. 3+. extensor
Rt: 3+. 3+. 3+. 4+. 3+. extensor
Pupils : NS NR
PROVISIONAL DIAGNOSIS : POST TRAUMATIC QUADRIPLEGIA WITH LMN TYPE BLADDER .
INVESTIGATIONS
ECG
