GM Paraparesis case of 23yr old Elog
N.DURGA MAHADEV
8th Semester Roll No. 118
A case of 23yr old paraparesis
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.
After going through the patient details as given by our Intern Mam through the following link..
https://vaish7.blogspot.com/2020/05/medicine.html?m=1
As of coming to the I want to keep the chief complaints in a priority order
A 23 yr old male patient has “complaints” -
1)weakness of bilateral lower limbs since 5 days
2)when he got up for urination ,suddenly he had a fall and got up with the help of father.
3)complaints of tingling and numbness
4)vomitings 5days back 3-4 episodes non projectile non bilious food particles is content.
6)scrotal abscess since 20 days(incision and drainage 10 days back)
7)gluteal abscess since 5months (operated 5 months back)
PAST HISTORY
Main complaint which is considered is “mutiple sex partners”
Coming to motor system examination ,which clearly shows that there is lower limbs deficit
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
Coming to the MRI images of brain n spinal cord
The report suggests that “There is significant enhancement which represents meningeal enhancement or exudates and following lesions in mri with multiple nodules in pulmonary apices suggest of pulmonary kochs and disseminated tuberculosis.“
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)
TREATMENT :
T.ATT 3 tabs/day fdc
T.Benadon 40mg/od
T.pregabalin 75mg/po/h/s
OINT.MEGAHEAL FOR LOCAL APPLICATION
SITZ BATH WITH BETADINE TID
FREQUENT CHANGE OF POSITION
My interpretation of the above case is that
Weakness of the lowebimbs can be due to trauma,vascular,or any infectious cause
As there is no history of any trauma and any signs of inflammation
It can be any infectious cause as he had history of multiple sex partners.
Abnormalities found in LFT : SGOT (AST) : 80 IU/L (NORMAL: <40 IU/L)
Alkaline Phosphate 192 IU/L ( NORMAL : 4O TO 129 IU/L )
As of now
Provisional diagnosis can be TB
And he should be started with TB treatment as soon as possible
Abnormalities in the LFT can be due to TB effecting liver.
(There is no sign of TB in lungs. As chest Xray doesn’t show any TB signs)
The signs are suggestive of UMN and LMN . so a detail examination should be done in order
To elicit which is dominant and to localize the exact location of the lesion.
Investigations that should be done
1. HIV (rapid testing kit)
2. TB (culture or PCR)
3. CT of Spine
My questions on this case
1.why the patients needs to change the positions frequently?
2.why he hasnt been started on TB drugs provisionally?
3.HIV & TB can be associated in most of the cases why hadnt the test been done?
4.why there is no culture test on gluteal and scrotal abscess?
My references
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