48year old male with lower backache

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A 48 yr male who is a toddy collector by occupation came to the OPD with C/O difficulty in walking since 22 days, swellings of B/L feet since 15 days, difficulty in lifting Rt arm since 15 days. 

HOPI:

‌Pt was apparently asymptomatic 1 month ago then he developed pain in the back which is pricking type, radiating down to buttocks and not relieved on rest. 

He went to RMP to get some medication(injection, tablets, spray) for the pain and used it for 4 days which did not provide any relief. 

Then the pt was taken to some orthopedic hospital in kodada in view of unrelieved pain .There the doctor advised some investigations and told the pt that he should avoid climbing trees and follow the advised medication for one week. 

‌he was alright for 5 days after returning from kodada then he suddenly became bedridden so again he was taken to kodada hospital, after seeing blood reports doctor advised to go to khammam. 

They went to RMP got treated for 4 days along with foleys catheterization. Then he developed chills, yellowish discoloration of eyes then they have taken him to khammam and admitted for 3 days there they found pedal edema, got discharged and took medication in home for 5 days. 

Again they went to khammam for follow-up. after 5 days he got fever which was relieved on medication, RMP diagnosed as typhoid and gave medication for 3 days. After that again the pt has complaints of backpain, swelling of legs and came to our hospital for further evaluation.

No h/o vomitings,night sweats, weight loss. 

PAST HISTORY:

Not a known case of DM/HTN/asthma/epilepsy.

He had a H/O trauma ( fall from tree ) 1 yr ago. 

PERSONAL HISTORY:

Diet : mixed

Appetite : normal

Bowel : Regular

Bladder : Foley's insitu

Habits/Addictions : alcoholic (40ml / day) since 20 yrs. 

smoking since 5 yrs(1 pack/ month) .

chews betel leave since 30 yrs

FAMILY HISTORY: not significant. 

General examination:

Pt was conscious, coherent, cooperative, moderately build and nourished. 

Pallor - present

No signs of  cyanosis, clubbing, icterus, koilonychia, lymphadenopathy. 

B/L pedal edema upto ankle. 

(Grade-I) 



B/L pedal edema

CTEV

      

                                

                       Scoliosis

Vitals:

Bp-110/70of mm Hg right arm, supine position. 

PR-102 BPM

RR-33 CPM

Temp-98°F

SpO2-99%

GRBS-130 mg/dl

SYSTEMIC EXAMINATION:

P/A: 

Umblicus inverted

abdomen is soft non tender

 No organomegaly

Bowel sounds heard. 

Hernial orrifices -free

CVS:

S1&S2 heard, No murmurs

CNS:

Higher mental functions  normal

Oriented to place, time, person

Speech is normal in pitch and tone

Memory: recent and remote memory intact

All cranial nerves intact

Motor:

                             Left                      Right

Bulk:

UL                          N                         N

LL                          wasting +           wasting+

                          (Thigh and calf muscles) 

Tone:

UL                         N                           N

LL                          N                          N

Power:

UL               - F       5/5                      5/5

       Elbow

                    - E       5/5                      5/5

LL       

                   - F        4/5                      4/5

       Hip     

                   - E         4/5                     4/5

                   - F          4/5                    4/5

       Knee

                   - E           4/5                    4/5

                   - F           4/5                    4/5

       Ankle

                   - E           4/5                     4/5

       EHL                    3/5                     3/5

       FHL                    3/5                     3/5

Superficial reflexes:

                             Left                         Right

Corneal:              present                present

Conjunctival:     present                 present

Abdominal:        present                 present

Plantar:                   -                           -

Deep tendon reflexes 

                                Left                       Right

Biceps                      +                            +

Triceps                     +                            +

Supinator                 +                            +

Knee                          -                             -

Ankle:                        +                            +

   

   

Sensory:

Fine touch:               N

Crude touch:            N

Pain temp:               N

Vibration:                 N

Joint position:        N

Proprioception:      N

No cerebellar signs

RESPIRATORY:

BAE +

Normal vesicular breath sounds

No added sounds.

Day - 1 

Investigations

 CBP, CUE, ECG

removal of Foley's catheter and placement of new Foley's catheter. 

TREATMENT

1) Tab.Ultracet po/bd

2) Tab. Pan 40 mg od

3) Tab. Mvt po/od

4) Tab. Shelcol po/od

5) Tab. Augmentin 625mg po/bd

6) Inj. Optineuron 1 amp in 100ml NS over 1 hr

Day - 2 

Investigations

LFT, RFT, CBP, serum iron, CRP, ESR

    

Blood transfusion done. 

Ortho refferal

Provisional diagnosis:  ?paraperesis 2° to dorsolumbar spondylosis with scoliosis with iron deficiency anemia

TREATMENT

1) Tab.Ultracet po/bd

2) Tab. Pan 40 mg od

3) Tab. Mvt po/od

4) Tab. Shelcol po/od

5) Inj. Augmentin 1.2gm IV/BD

6) 1 - PRBC transfusion

7) Proteinex powder 2 Ts in glass milk TID

8) 2 Boiled egg white

Day - 3

Pt C/O lower back pain, constipation, unable to lift rt arm above shoulder. 

Treatment

1) Tab.Ultracet po/bd

2) Tab. Pan 40 mg od

3) Tab. Mvt po/od

4) Tab. Shelcol po/od

5) Inj. Augmentin 1.2gm IV/BD

6) Proteinex powder 2 Ts in glass milk TID

7) 2 Boiled egg white

8) Tab. Orofer - XT BD

Day - 4

Pt C/O lower back pain, constipation, unable to lift rt arm above shoulder

Treatment

) Tab.Ultracet po/bd

2) Tab. Pan 40 mg od

3) Tab. Mvt po/od

4) syp. Duphalac 15ml

5) Inj. Augmentin 1.2gm IV/BD

6) Proteinex powder 2 Ts in glass milk TID

7) 2 Boiled egg white

8) Tab. Orofer - XT BD

9) surgery refferal for constipation. 

MRI RADSPA link

http://pacs.kaminenihospitals.com:99/WADO/MetaData?aet=AEKIMS&studyUID=1.3.12.2.1107.5.2.40.38559.30000020082404413639000000013&sessionKey=263220d9-f6d6-4374-a03c-80524c1ce389&src=Vijaya