36Y Male suffering from Quadriplegia


17th June 2023

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

This is the case of a 36-year-old male, resident of West Bengal, and Fish seller by occupation. The following history was taken with the patient in person. The patient was explained about confidentiality and written consent was taken to create the following case report.


This case report aims to record the patient's journey.

CHIEF COMPLAINTS:- 

History of present illness:-

The patient was apparently asymptomatic 3 months back then he met an RTA skid and fall from 2 wheeler on 7.03.23 (Holi) around 9:00pm. As soon as the accident happened, he got unconscious and was taken to a local hospital, where it was said that he injured his back. According to the patient, he was unconscious for a whole day. After regaining conciousness, the patient was unable to move both of his legs, was able to partially flex his elbow to a certain extent. The patient was unable to clench his fists completely on both sides, with the left hand having more power than the right. There was pain on both of the wrists, radiating to all of the fingers and being throbbing in type, and continuous in nature. However currently, the progression of the intensity of the pain is decreasing and the patient is able to clench his fists on both sides to some extent. 

The patient also mentions experiencing hip pain due to the injury he has sustained when he was in the hospital. This pain lasted for two to three days, and disappeared after that. 

On 10.03.23, the patient was admitted to another hospital where the following investigations were done:-

 1) NCCT of the brain was done. it has ruled out the presence of any head injury.

2) MRI OF SPINE spine was done, which suggested disc bulges (lesions) at L4-L5, L5-S1 and C3-C4, C4-C5. 

The Patient was later advised to undergo physiotherapy.

Upon admission to the OPD, the patient presented with the following symptoms:-

1) the patient was unable to use both the lower limbs voluntarily. The severity of the condition is a paresis and the progression of the condition is static and chronic. He was not able to sit initially after the accident but now he can sit on his own without an attendant.

2) Slight neck pain felt when patient is lifting his head. Pain is described as throbbing type, and aggrevated when the patient is lifting his head. 

3) he also complained of tightness around the abdomen (Band like sensation/girdle like sensation) 

4) The patient also complained of  retention of urine  able to feel the fullness of the bladder but is unable to initiate micturition for which a catheter is inserted since 2 months. 

Other observations include:- 

1) The patient was unable to comb the hair since the time of the accident, but he able to take the food to the mouth by himself. 

2) The patient was unable to button the shirt by himself since the time of the accident.  

3) The patient was able to squat and getting up from the squatting position with help, but he cannot climbing stairs up and down or walk by himself. 

4) The patient cannot perform slipping of chappals, and there is no tripping of toe.  

5) The patient with help, can roll over the bed, and get up from the bed.

6)No Difficulty in breathing. 

7) There is no diurnal variation of weakness.  

Negative history

No h/o visual disturbances, headache, diplopia, ptosis he is able to appreciate smell, hes able to look towards all sides no h/o sensory loss over the face, no facial deviation. 

No noted sensory deficit as the patient was able to feel clothes, feeling hot and cold water while bathing. 

No h/o auditory disturbances

No h/o restricted tongue movements

No difficulty in swallowing

No difficulty in speaking

No h/o abnormal sweating

No h/o shooting pain

No h/o headache or vomiting.

No h/o seizures

No h/o Fasciculations/muscle twitchings.

No h/o Involuntary movements like chorea, athetosis, tremors, hemiballismus

-------------------------------

PHYSICAL EXAMINATION:-

GENERAL EXAMINATION:-

The examination was conducted at a well lit and well ventilated room. The patient was conscious, cooperative and coherent. 

Moderately built

Afebrile

No Palor

No Icterus

No Cyanosis

No Clubbing 

No Pedal edema

No Significant lymphadenopathy

CNS EXAMINATION:-

Bulk  

                          rt         lf

Arm             23 cm    23cm

Forearm      24cm      24cm

Leg              29cm      29cm


Tone

                               rt                      lf

Arm                   increased      increased

Leg                    increased     increased


Power

                                   rt                 lf

Deltoid                      5                  5

Supraspinatus         5                  5

Infraspinatus           5                  5

Pectoralis major    +4                +4

Biceps                     5                   5

Brachioradialis      5                    5

Triceps                  -4                   -4

ECR                        5                    5

ECU                       5                     5

Extensor digitorum  -4               -4

FCU                            3                 -4

Abductor pollicis longus  -4        +4

EPB                          -4                  +4

Opponens pollicis -unable to do on both-

Abductor pollicis brevis  3           +4

Adductor policis            -4              4

Lumbricals and interossei

          Test one              -4                   -4

          Test two              3                     3


Lower limbs

Illeopsoas                    3                     -4

Adductor femoris       -4                    +4

Gluteus medius and minimus  5                 5

Gluteus maximus          3                     3

Hamstrings                   +4             -4

Quadriceps                    +4              +4

TA                                   -4                +4

TP                                   +4                +4

Peronius                         -4                 +4

Gastrocnemius             +4                 +4

EHL                                +4                   -4

Extensor digitorum longus   3             3

Flexor Digitorum Longus      5            +4                       

History of past illness:-

The patient does not have any history of TB, HTN, DM, Epilepsy and asthma. 

Personal history:-

Water intake:- normal

Appetite:- normal

Diet:- mixed 

Bowel movement:- constipation since accident. Passes stool only after administration of laxative. 

Bladder movement:- currently catheterised. Unable to pass urine since the accident. 

Alcohol:- Before the accident, used to consume every 5 days but after the accident there has been no consumption. 

Smoking:- nil

Addiction:- consumes supari on daily basis. 

Allergies:- nil

Exercise status:- nil

CLINICAL PICTURES AND VIDEOS:-

RADIOLOGY REPORT:-

REPORTS:-

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