36Y Male suffering from Quadriplegia
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
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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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