A CASE OF PARAPARESIS PRESENTED IN SUMMER 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 45 yr old female came to the OPD with complaints of weakness in the lower limbs and difficulty in swallowing food .
Date of Admission: 01/06/23
CHIEF COMPLAINTS
➤ Weakness in lower limbs since Jan 2023.
➤ Difficulty in swallowing food since last 10 days .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic untill 1999 i.e till the delivery of her baby . Then she started developing weakness in her lower limbs but it wasn't associated with pain (she was able to perform daily activities) .
She stopped working in 2012, due to B/L weakness of lower limbs , associated with pain , but continued to do household chores with pain .
In Jan 2023 , she had H/O slippage in the bathroom, following which she was normal and could walk for 5 days . However on the morning of 6th day , she couldnt get up from the bed , the weakness in her LL was sudden in onset , non progressive. Due to this she couldn't resume her daily activities.
She was taken to a local hospital and her Xray and MRI-scan were done . Xray was found to be normal and MRI reports aren't present .
At that time patient had c/o stoppage of urine , following which Foley's catheterisation was done , then she had normal passage of urine . Her condition was the same for last 10 days , after which she had c/o difficulty in swallowing (especially solids ) associated with pain .
HISTORY OF PAST ILLNESS
➤ She has difficulty in getting up , combing her hair .
➤Not a k/c/o diabetes mellitus, hypertension, bronchial asthma ,epilepsy, tuberculosis.
PERSONAL HISTORY
➤Occupation: House - help
➤Patient is single.
➤Patient is eggtarian .
➤Sleep : Regular
➤Bladder and bowel movements are normal.
➤No known allergies .
➤No known addictions.
FAMILY HISTORY
Not significant .
GENERAL EXAMINATION
➤Pallor : seen
➤Icterus : not seen
➤Cyanosis : not seen
➤Clubbing : not seen
➤Lymphadenopathy : not seen
➤Edema : not seen
VITALS
➤Temperature : 98.4℉
➤PR : 78 beats per minute
➤BP : 100/60 mm of Hg
➤RR : 18 cycles per minute
➤SpO2 : 99% in room air
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.
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
➤ Glascow Scale - 15/15
➤Reflexes. B T. S. K. A. plantar
Lt: 2+. 1+. -. -.M
Rt: 2+. 1+. -. -. M
Neck stiffness: no
Kernig's sign : no
PROVISIONAL DIAGNOSIS : PARAPARESIS SECONDARY TO TRAUMA .
TREATMENT
1) Tab. MVT PO/OD
2) I/O charting
3) SVP Lactulose 15ml PO/BD
