A 60 year old male with quadriparesis

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

13/08/2022

Blog by Janhavi Virani 

Roll no 58 

A 60 year old male patient resident of Yadadri who is a farmer by occupation came with complaints of - 

1. Burning micturition since 4 months 

2. Abdominal distension since 2-3 months 

3. Upper and lower limbs swelling since 20 days 

 4. constipation since 4 days

HOPI - 

Patient was apparently asymptomatic 11 years back when he got some injury to his right knee followed by which he developed swelling ( hematoma ) and went through operation. 

4 and half year back he fell down had a injury to the lower back region following which he had weakness of  all four limbs . For 2 months he took conservative management ( eating fish and eggs ) regained power gradually and was able to walk initially and later was able do some of his daily chores . Since last two years he is not able to walk at all . 

4 years back patient developed gradual decrease in the urine output and retention with abdominal discomfort and SOB . When he was diagnosed with ? (BPH) Obstructive Uropathy . He was put on foleys catheter- changing every 7-10 days since 2 years . 

1 year back similar complaints of sudden weakness of all four limbs with gradual recovery for 2-3 months . 

4 months back bilateral lower limb swelling gradually increased and spread to upper limbs . Abdominal distension and burning micturition.  

4 days back patient complained of abdominal discomfort associated with constipation and passing flatus . 

PAST HISTORY- 

No H/o diabetes, hypertension, thyroid abnormality , CAD , epilepsy, TB , asthma. 

SURGICAL HISTORY- 

Patient went through some surgery ( unknown) 11 years back following injury to right knee. 

DRUG HISTORY- patient is not allergic to any drug . 

FAMILY HISTORY- no significant family history 

PERSONAL HISTORY- 

Diet - Mixed 

Appetite- normal 

Sleep- adequate 

B & B - Foleys catheter- changes once in 7-10 days since 2 years 

              Burning micturition since 4 months 

              Decreased urine output since 4 months 

              Constipation with passing flatus since 4 days 

Addictions- smoking since when he was 20 years old ( 3/day ) 

                    Stopped smoking since 2 years 

                    Occasional toddy drinker , stopped since 2 years 

GENERAL EXAMINATION- 

Patient in conscious, coherent and cooperative 

Moderately built and nourished 

Pallor- present 

Icterus- absent 

Clubbing- absent 

Cyanosis- absent 

Lymphadenopathy- absent 

Edema- present in B/L upper and lower limb 

VITALS - 

BP - 130/80 mm of Hg 

PR - 84bpm

RR- 17cpm

Temperature- a febrile 

SYSTEMIC EXAMINATION- 

Cardiovascular system  

JVP - not raised 

Visible pulsations: absent 

Apical impulse : left 5th intercostal space in midclavicular line.

Thrills -absent 

S1, S2 - heart sounds heard 

Pericardial rub - absent

Respiratory system:

Patient examined in sitting position

Inspection:

Shape of chest - normal

Chest movements : bilaterally symmetrically 

Trachea is central in position.

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

Chest movements bilaterally symmetrical 

AUSCULTATION 

BAE+,  NVBS

Abdomen examination:

INSPECTION

Shape : distended 

Scar : Absent 

Umbilicus: slit like 

Movements : normal 

Visible pulsations :absent

Skin or surface of the abdomen : normal 

PALPATION 

Tenderness: absent 

PERCUSSION- tympanic

AUSCULTATION :bowel sounds heard

CNS examination:

Higher mental functions : intact 

Patient is conscious, coherent and cooperative and well oriented to time , place and person . 

Cranial nerve examination: intact 

Motor system: 

Tone -           

Upper limb   Hypotonic 

Lower limb   Hypotonic 

Power -             Rt.              Lt 

Upper limb        2/5.            3/5

Lower limb        2/5.            2/5

Reflexes-   B.   T.    S.    K.   A.    P.  

Right          —   +    —    —   —   Babinski +

Left            ++  ++   +     ++   +    Babinski +

Sensory examination: normal 

Gait : cannot be accessed 

Involuntary movements : absent 

PROVISIONAL DIAGNOSIS- 

Quadriparesis secondary to trauma 

Chronic Renal failure 

INVESTIGATIONS- 

Hemogram , serum electrolytes, blood urea , serum creatinine , LFT 

11/8/22

ECG 

Echocardiogram- (2D Echo) 

USG abdomen 

Chest X-ray - 

Abdominal X-ray - 

CT Abdomen and Pelvis- 

Urine culture- 

TREATMENT- 

Inj Lasix 40mg / iv / TID

Inj PAN 40 mg / iv / TID 

Inj Optineuron lamp in 100ml /NS/ iv / OD 

Tab Nodosis 500 mg /PO/ BD 

Tab shelcal 500 mg /PO/ BD

Ecosporin 75/ 10 mg /PO/OD

Fluid and salt restriction 

BP / PR / Temp monitoring