23yrs old male patient with paraparesis by y.abhinav roll no:181

I've 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 a diagnosis and treatment plan. 

 Cheif complaints : 

1)weakness of bilateral lower limbs since 5 days

complaints of tingling and numbness 

2)vomitings 5days back 3-4 episodes non projectile non bilious food particles is content.

3)when he got up for urination,suddenly he had a fall and got up with the help of father.

4)gluteal abscess since 5months 

5)scrotal abscess since 20 days

Explanation of the above problems

 

1) weakness of the lower limbs

    As their are many causes  for weakness of lower limb 

 

A. Stroke

A stroke occurs when the blood supply to your brain is cut off because of a blockage, or a blood vessel in the brain bursts. It can cause sudden numbness or weakness in the face, arms, or legs.

Other signs and symptoms of stroke include:

• sudden confusion
• Difficulty in speaking
• sudden, severe headache
• drooping of one side of the face or uneven smile
• 
  
•  As thier are no other associated causes it may not be stroke  

 

B. Slipped disc

A slipped disc occurs when the gelatinous substance inside the discs that cushion your vertebrae protrudes through a tear in the exterior, causing pain. This can happen because of injury or age-related degenerative changes in the spine.

If the slipped disc compresses a nearby nerve, it can cause pain and numbness along the affected nerve, often down your leg.

Other symptoms include:

• Muscle weakness 
• pain that’s worse when standing or sitting
• tingling or burning sensation in the affected area

C. Guillain-Barré syndrome

It is a rare autoimmune disorder in which your immune system attacks your nerves, causing tingling and weakness that usually begins in the feet and legs. The weakness can spread quickly and eventually paralyze the whole body if not treated right away.

Other symptoms can include:

• prickling or pins and needles sensations in your wrists, fingers, ankles, and toes
• severe pain that worsens at night
• difficulty with eye or facial movements
• problems controlling your bladder or bowels

The cause of the condition isn’t known, but it’s often triggered by an infection, such the stomach flu or a respiratory infection. 

As given according to the case thier is no stomach flu and respiratory infectio  so we can rule out gb syndrome

D. Pinched nerve

Sciatica, which is caused by a pinched nerve in the lower back, is pain that radiates along the sciatic nerve, which extends from your lower back through your hips and buttocks and down the legs. It usually affects one side of your body.

Sciatica can range from a dull ache to sharp burning pain, and worsen with prolonged sitting or sneezing. You may also experience leg numbness and weakness.

Mild sciatica usually goes away with rest and self-care measures, such as stretching. See your doctor if your pain lasts longer than a week or is severe.

 As we have gone through various causes we can also see causes through cns involvement 

E. Multiple sclerosis

Ms is an autoimmune disease of the central nervous system. In MS, your immune system attacks the myelin, which is the protective sheath around your nerves. It’s most often diagnosed in people aged 20 to 50.

MS can cause a wide range of symptoms that vary from person to person. Numbness and fatigue are the most common symptoms. Other symptoms include:

• muscle weakness
• Muscle spasm
• difficulty walking
• Tremors
• acute and chronic pain
• Visual disturbance 

F.Peripheral neuropathy

It is nerve damage to your body’s peripheral nervous system, which connects the nerves from your central nervous system to the rest of your body.

It can be caused by injury, infection, and a number of conditions, including diabetes and hypothyroidism.

Symptoms usually start with numbness or tingling in the hands and feet, but can spread to other parts of your body. Other symptoms include:

• weakness
• pain that worsens at night
• burning or freezing sensation
• shooting or electric-like pain
• difficulty walking

G.Parkinson’s disease

Parkinson’s disease is a neurodegenerative disorder that affects an area of the brain called the substantia nigra.

Symptoms of the condition develop gradually over the years. Problems with movement are usually the first signs. Other symptoms include:

• small handwriting or other writing changes
• slow movement 
• limb stiffness
• problems with balance or walking
• tremors
• voice changes

These are the some of cns cause can lead to lower limb weakness

 So we have gone through

  cns Examination ;

 

Cns conscious

speech-normal

cranial nerves intact.

MOTOR SYSTEM 

                         Right.         Left

Bulk:               normal.      Normal

Tone: ul.        normal.       Normal

           LL.       hypotonia    hypotonia

Power          rt.          lt

         ul.        5/5.      5/5

         LL.       2/5.      0/5

Reflexes.  

   Superficial reflexes

                       Right.           Left

Corneal.        P                   P

Conjunctival P.                  P

Abdominal.   P.                  P

Plantar          Extensor   Extensor

    Deep tendon reflexes 

                     Right.             Left

Biceps.        2+                  1+

Triceps.       2+                   1+

Supinator.    3+                   2+

Knee             3+                  2+

Ankle.           3+                  2+

jaw jerk.        1+.                1+

ankle clonus present.     absent

Primitive reflex -absent

Involuntary movements - absent

  

As we have seen the above cns examination we can understand that their is hypotonia , hyporeflexia , paraplegia characteristic of lower motor neuron lesion

Other investigations

MRI OF BRAIN AND SPINAL CORD SHOWS FOLLOWING

According to the mri thier are exudates with multiple nodules in pulmonary apices significant of disseminated tb

MRI spine

Mri images of the Brain

2.Vomiting 

The causes of vomiting differ according to age. For children, it is common for vomiting to occur from a biral infection, food poisoning, milk allergy, motion sickness, overeating or feeding, coughing, or blocked intestines and illnesses in which the child has a high fever.

The timing of the nausea or vomiting can indicate the cause. When appearing shortly after a meal, nausea or vomiting may be caused by good poisoning, gastritis(inflammation of the stomach lining), an ulcer. Nausea or vomiting one to eight hours after a meal may also indicate food poisoning. However, certain food- borne bacteria, such as salmonella, can take longer to produce symptoms.

Usually, vomiting is harmless, but it can be a sign of a more serious illness. Some examples of serious conditions that may result in nausea or vomiting include concussion, meningitis (infection of the membrane linings of the brain), intestinal blockage, appendicitis, and brain tumors.

3.Gluteal abcess 

 Operated 5 months back

4.scrotal abcess 

   Operated 10days back

These two abcess are cold abcess as there is no signs of inflammation.

  

  As we have already treated the patient thier is chance for recurrence so we can go for scraping and send it for culture and identify the organism so that we can prescribe the antibiotics based on the organism 

As we are thinking of tb to find out the mycobacterium their are other investigations to find out 

As the patient is found to have disseminated TB, it is important to ruleout TB Spine (Potts Spine)

Potts spine may cause Potts paraplegia involving both the lower limbs. 

•Its is also important to ruleout Spondylodiscitis as M.tuberculosis is one of the main causative organism.

1. Tuberculin skin test 

2. Surgical biopsy

3.sputum microscopy

4.culture of abscess fluid

 from the above investigations we can be able to confirm which type of mycobacterium it is and further treatment option is done.

.Etiology of Paraplegia

The cause of the paraparesis is infarction of the spinal cord secondary to embolism in the artery of Adamkiewicz. This artery arises from the aorta, at the T10 to T12 level of the aorta and is the major segmental artery to the thoracolumbar cord.

the artery of Adamkiewicz (also arteria radicularis magna) is the largest anterior segmental medullary artery. It typically arises from a left posterior intercoastal artery at the level of the 9th to 12th intercostal artery, which branches from the aorta, and supplies the lower two-thirds of the spinal cord via the anterior spinal artery. 

 

So , as thier the organisam in lumbosacral region can enter through the blood vessels and move to the higher blood vessel can get blocked thier and causes these kinda of symptoms 

Provisional diagnosis 

Paraparesis with L4,L5infective spondylodiscitis with left psoas abscess with ring enhancing lesions in right and left cerebral hemispheres with healing ulcer in right gluteal region secondary to drained gluteal abscess with pyocele left side operated ( 10 days back) 

Given therapeutic treatment 

1)T.ATT 3 tabs/day fdc

2)T.Benadon 40mg/od

3)T.pregabalin 75mg/po/h/s

4)OINT.MEGAHEAL FOR LOCAL APPLICATION

5)SITZ BATH WITH BETADINE TID

6)FREQUENT CHANGE OF POSITION

Conclusion 

 

As i have seen the case from one end to the final end my thought process told me to suggest some more test to be done 

 1) As he is having multiple sexual partners thier may be chance of hiv positive 

2) so we can through hiv rapid test , western blot , ELISA

3) so if he is positive we can go given him ealr anti - retrovirals

4)CT-scan  finally we can make him go through ct so that we can find out any other sympots which mught be missed through mri like edema etc..

 5) finally thier is a difference between paraparesis and paraplegia as our case is with paraparesis- it is a partial paralysis of the lower limbs.

Paraplegia- paralysis of the legs and lower body, typically caused by spinal injury or disease.

  As this is my analysis for a 23yr old male case with paraparesis