34 yr/M with COMPRESSIVE MYELOPATHY

February ,2023

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Name : SANTOSH KUMAR .K ( Intern ) 

Roll Number : 62

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 diagnosis and treatment plan. 

Chief compliants

34 yr old male ,autodriver by occupation presented with c/o weakness of left lower limb since 3 months 

Tingling sensation of left foot since 2 months

HOPI

Pt was apparently asymptomatic 7 months back then he noticed weakness in his left lower limbsb insidious onset , gradually progressive associated with decreased sensations since past 3 months and tingling sensation of left foot since 2 months 

He went to neurosurgeon on 24/8/2022 and was advised MRI dorsal spine which was normal .pt complaints did not resolve and he came to our hospital now

H/o difficulty in gripping his foot wear 

H/o difficulty in getting up from squatting position 

H/o difficulty in climbing upstairs and downstairs 

No H/o involuntary movements

H/o head trauma 10 yrs back (not associated with loss of consciousness , vomiting)

NoH/o LOC, memory loss,loss of smell, decreased vision, difficulty in chewing , deviation of mouth , dribbling of saliva

No H/o diplopia ,loss of hearing,hoarseness of voice 

NoH/o deviation of tongue 

H/o swagging positive 

No H/o bowel and bladder incontinence

NoH/o fever, vomiting ,headache 

Past history

Not a know n case of epilepsy ,HTN ,T2DM ,CAD,CVA,ASTHMA, THYROID DISORDER.

Personal history

DIET- mixed

Appetite: Normal

Bowel and bladder movements are regular

Sleep: adequate 

No allergies

Occasional alcoholic 

General examination

Pt is conscious , incoherent, co-operative

No  pallor 

      Icterus

      Cyanosis

       Clubing

       Lymphadenopathy

        Edema

Vitals

         BP 110/70mmhg

         PR 76 BPM

         RR 18 cpm

         Spo2 98

Grbs. 108 mg/ dl

Systemic examination

       Respiratory examination

        BAE +ve and normal vesicular breath sound heard 

        No crepts heard 

      CVS examination

       S1S2 heard 

        No murmurs heard

        Abdomen examination

        Soft non tender

        No hepatomegaly and splenomegaly

CENTRAL NERVOUS SYSTEM EXAMINATION- 

Higher mental functions

- Conscious

- Oriented to time,place and person

- Memory - Intact

- Speech - no deficit

Cranial nerve examination 

          • 1 - olfactory sense - normal

          • 2- Direct and indirect light reflex present

          • 3,4,6 - no ptosis and nystagmus

All eye movements were normal

 • 5- Touch - 

Sensory -by cotton and pin felt

 Motor - chewing movements seen             

           • 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present

          • 8- Hearing normal 

          • 9,10- position of uvula is central

No regurgitation after drinking water

          • 11- looked for trapezius muscle - contraction present

          • 12- no deviation of tongue on protrusion

Motor system 

Attitude - left and right lower limb slightly flexed at knee joint in lying down posture

Reflexes 

                          Right   Left            

Biceps               -               -

Triceps              -               -

Supinator           -               -

 Knee. .              +3            +2

Ankle.                 +2.          +2

Babinski. B/L extension of great time is seen      

                            

Power

Upper limb -5/5

Lower limb -5/5                                         

               

TONE. Lt. Rt

 Upper limbs N N                

 Lower limbs N N                 

No involuntary movements

SENSORY SYSTEM

I – SPINOTHALAMIC R L

1. Crude touch N N 

2. Pain. N. N

II – POSTERIOR COLUMN

1. Fine touch. N. N

2. Vibration sense not felt on Lt lower limb but it slightly felt on rt lower limb             

3. Position sense. N. N

4. Romberg’s sign - positive

III – CORTICAL

1. Two point 

    discrimination.               

2. Tactile localisation. Not localised at some points and he delayed to localise the point at other regions in both lower limbs 

3. Graphaesthesia. N. N

4. Stereognosis. N. N

Finger nose Coordination present 

No dysdiadokinesia 

Knee heel coordination present 

Gait. Appear to be normal 

         Swaying seen when he walks on narrow path

And discomfort seen while walking down stairs

Provisional diagnosis 

C5- C6 compressive MYELOPATHY 

Investigation

Electrolytes

Na 139

K.  4.2

Cl. 104

Blood urea  26

S creatinine  0.9

RBS 95

FBS 87

Hba1c 6.5%

Hemogram 

Hb 10.6

TLC 8200

PLT 2.27

CUE

Albumin and sugar nil 

Serology 

Negative 

2d echo

EF 62%

TRIVIAL TR+,AR+ , No MR

No RWMA ,No As/MS 

Good Lv systolic function 

No diastolic dysfunction ,no pah.

Ecg 

MRI cervical  spine  with whole spine screening

C3-C4,C4-C5,C6-C7 disc degeneration 

C5-C6 disc osteophyte complex causing mederate cord compression with cord edema /early myelomalacia

Treatment

 Pregabalin M 75po/hs 

Definitive treatment 

Pt need s anterior cervical  decompression and fusion