60yr male with quadriplegia

 This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

CASE:

A 60 year old male patient resident of Yadadri who is a farmer by occupation came with complaints of Abdominal distension since 4 months ,Burning micturition since 4 months, Upper and lower limbs swelling since 1month constipation since 7days.

History of presenting illness:

Patient was apparently asymptomatic 11 years back when he got some injury to his right knee followed by which he developed swelling ( hematoma? ) and went through operation. 

4 and half year back he fell down had a injury to the lower back region following which he had weakness of all four limbs . For 2 months he took conservative management ( eating fish and eggs) regained power gradually and was able to walk initially and later was able do some of his daily chores . Since last two years he is not able to walk at all. 

4 years back patient developed gradual decrease in the urine output and retention with abdominal discomfort and SOB . When he was diagnosed with ? (BPH) Obstructive Uropathy . He was put on foleys catheter- changing every 7-10 days since 2 years as he is completely bedridden due to paralysis of all the 4 limbs

4 months back bilateral lower limb swelling gradually increased and spread to upper limbs . Abdominal distension and puffiness of face.

7days back patient complained of abdominal discomfort associated with constipation and passing flatus . Burning micturition since 4 months.

Past history:

No history of similar complaints in the past. 

No H/o diabetes, hypertension, thyroid abnormality , CAD , epilepsy, TB , asthma. 

Surgical history:

Patient went through some surgery ( unknown) 11 years back following injury to right knee. 

Family history:not significant.

Personal history:

Diet - Mixed 

Appetite- normal 

Sleep- adequate 

B & B - Foleys catheter- changes once in 7-10 days since 2 years

       Decreased urine output since 4 months 

       Constipation with passing flatus since 4 days 

Addictions- smoking since when he was 20 years old ( 3/day )

     Stopped smoking since 2 years 

     Occasional toddy drinker , stopped since 2 years 

GENERAL EXAMINATION- 

Patient in conscious, coherent and cooperative 

Moderately built and nourished 

Pallor- present 

Icterus- absent 

Clubbing- absent 

Cyanosis- absent 

Lymphadenopathy- absent 

Edema- present in B/L upper and lower limb 

Clubbing- absent 

Cyanosis- absent 

Lymphadenopathy- absent 

Edema- present in B/L upper and lower limb 

 

Vitals:

Temperature- a febrile

BP - 130/80 mm of Hg 

PR - 84bpm

RR- 17cpm

SYSTEMIC EXAMINATION- 

Cardiovascular system:

S1, S2 - heart sounds heard , no murmurs heard. 

Respiratory system:

Inspection:

Shape of chest - normal

Chest movements : bilaterally symmetrical

Palpation:-

All inspiratory findings are confirmed

Trachea central in position.

AUSCULTATION:

BAE+, NVBS

Abdomen examination:

INSPECTION

Shape : distended 

Scar : Absent 

Umbilicus: everted

Movements : normal 

PALPATION 

Tenderness: absent 

PERCUSSION- tympanic

AUSCULTATION :bowel sounds heard

CNS examination:

Higher mental functions : intact 

Patient is conscious, coherent and cooperative and well oriented to time , place and person . 

Cranial nerve examination: intact 

Motor system: 

Tone - Right left

Upper limb Hypotonic Hypotonic 

Lower limb Hypotonic Hypotonic 

Power - Right left

Upper limb- 2/5. 3/5

Lower limb- 2/5 2/5

Reflexes- Right.               left 

      Biceps- -                      +++

   Triceps +++.                    +++

 Supinator -           +++

       Knee -          ++

       ankle -           ++

       plantar dorsiflexion dorsiflexion

Sensory examination: normal 

Gait : cannot be accessed 

PROVISIONAL DIAGNOSIS- 

Quadriparesis secondary to trauma (Lesion maybe above the level of C5 C6 level)

CKD 

INVESTIGATIONS-

11-8-2022

12-8-22

15-8-22

ECG

Treatment:

Inj Lasix 40mg / iv / TID

Inj PAN 40 mg / iv / TID 

Inj Optineuron lamp in 100ml /NS/ iv / OD 

Tab Nodosis 500 mg /PO/ BD 

Tab shelcal 500 mg /PO/ BD

Ecosporin 75/ 10 mg /PO/OD

Fluid and salt restriction 

BP / PR / Temp monitoring