Middle aged female bounded to wheel chair 🪑

CHIEF COMPLAINTS:-

A 39yr old lady, right handed individual, who is a house wife presented with a chief complaints of

1.Inability to walk since 6mnths

2.burning sensation from chest to toes

HOPI:-

Pt was a/a 6 months back when she went out for a evng walk near her home had sustained a fall due to slippage on a slippery surface. Following the event she herself got up and reached home with a pain in left hip. Over the next two day's she developed a insidious onset tight band like sensation all around the chest at the level of xiphisternum f/b abnormal Tingling sensation, burning sensation below the xiphisternum to toes . In next couple of day's she noticed difficulty in sitting or getting up from a chair or lying down position or turning on bed. She also noticed stiffness in both lower limbs.

Though she was unable to walk she used to crawl with help of upper limbs & do her routine activities like mixing food, grooming, washing clothes...etc but after 1mnth she started noticing stiffness in her upper limbs & difficulty in doing above all activities.

No electric shock like sensation radiating to leg & no shock like sensation on bending neck.

No sharp shooting pain in particular dermatomal pattern

No c/o neck or upper limb muscle weakness / respiratory distress

No muscle fasciculations/ wasting

No h/o Headache/vomiting/seizure/ speech abnormality/alteration in behaviour/reccurent hiccups

No h/o urinary urgency/frequency/ retention.

No h/o palpitation/postural dizziness/ loss of sweating.

No h/o any impairment in vision/ hearing/ speech/ chewing & swallowing.

No h/o skin rash,oral ulcers, alopecia, dryness of mouth.

No h/o wt loss, decreased appetite,

No h/o or contact to TB

No h/o recent vaccination / bleeding diathesis.

No h/o trauma In back

PAST HISTORY:-

No significant past history

No h/o Animal bite/ vaccination

No h/o blood transfusion

FAMILY HISTORY:-

No h/o similar complaints in family members

PERSONAL HISTORY:-

Diet- vegetarian , Takes egg🥚

Sleep- Adequate

B×B - Normal

No addictions /high risk behaviour

SUMMARY:-

A 39 yr old female with out any pre existing comorbidity developed chronic progressive spastic Quadriparesis ( LL > UL ) associated with decreased pain, Temp, vibration & joint position sensation in both LL , Trunk, upto Xiphisternum & feels a band like sensation at that level. Without bladder & bowel & clinically cranial nerve involvement.

GENERAL PHYSICAL EXAMINATION:-

Pt is conscious/ alert/ cooperative

Facies- Normal

Built- moderate

Nutrition- BMI- 22kg/m2

Decibitus- Legs extended at Hip, knee & plantar flexed

PICCLE - Absent

PR- 86bpm, regular, normal volume, no radio radial or radio femoral delay

BP- 130/80mmhg in supine

RR- 16cpm, Thoraco abdominal type

Temp- 98.6f

No engorged neck veins/ enlarged neck glands/ no oral ulcers / no neuro cutaneous markers

Cranium & spine normal, No vertebral tenderness noted.

HIGHER MENTAL FUNCTIONS:-

Pt is rt handed

GCS- 15/15

Conscious/ well Oriented to time place & person.

Memory- Immediate, recent, remote intact.

Speech- Normal

CRANIAL NERVES:-

Normal

MOTOR:-

Muscle bulk preseved in all limbs.

No fasciculations/ wasting seen.

Attitude-

Pt lying supine position with attitude of both lower limbs extended at Hip , knee & flexed at ankle

Both arms placed at sides

Nutrition-

Rt. Lt.

Arm. 24cm. 24cm

Fore arm. 19cm. 19cm

Thigh. 43cm. 42cm

Calf. 32cm. 32cm

TONE-

According to modified ashworth scale

Grade 1 spasticity in U/L

Grade 2 Spasticity in L/L

POWER-

UPPER LIMB-.

Rt. Lt

Shoulder

Abduction. 4/5. 4/5

Adduction. 4/5. 4/5

Flexion. 4/5. 4/5

Extension. 4/5. 4/5

Elbow

Flexion. 4/5. 4/5

Extension. 4/5. 4/5

Wrist

Dorsiflexion. 4/5. 4/5

Palmar flexion. 4/5. 4/5

Small muscles of both hands - 4/5

LOWER LIMB-

Rt. Lt

HIP

Abduction. 4/5. 4/5

Adduction. 4/5. 4/5

Flexion. 4-/5. 4-/5

Extension. 4/5. 4/5

KNEE

Flexion. 4/5. 4/5

Extension. 4/5. 4/5

ANKLE

Dorsiflexion. 4/5. 4/5

Plantar flexion. 4/5. 4/5

Small muscles of foot- 4/5

REFLEXES:-

Rt. Lt

B. 3+. 3+

T. 3+. 3+

S. 3+. 3+

K. 3+. 3+

A. 2+. 2+

PLANTAR B/L extensor

Abdominal reflex:- absent

SENSORY:-

spino thalamic

Crude touch,Pain,Temperature

She feels burning sensation below xiphisternum to feet & can't perceive any other

Post.column:-

Fine touch, Vibration,Proprioception- Decreased from xiphisternum, hip, knee, Ankle, in graded manner . 75%, 50%, 25% 0%

CEREBELLUM:-

no nystagmus, giddiness, FNF- normal

HKT- couldn't be tested

GAIT- couldn't be tested since even with 2 people support she couldn't walk & has her both legs stiff

MENINGEAL SIGNS:-

Absent

ANS:-

Resting tachycardia, abnormal sweating absent

OTHER SYSTEMS:-

CVS:- Apex beat in left 6th ICA 1cm medical to mid clavicular line

S1S2 heard no murmers

No raised jvp, engorged veins

RS:-

Bae+, Nvbs, No added sounds

ABDOMEN:-

Soft, non tender, no organomegaly

DIFFERENTIAL DIAGNOSIS:-

With the above history I would like to localize the lesion to Dorsal spinal cord at the level of T4 since it started acutely & involving most of the tracts probably Non compressive myelopathy.

Demyelinating ( MS / NMOSD )

Vitamin Deficiency - B12

Vascular

Infective

Para neoplastic