Case presentation:- 65yr F Quadriparesis with UMN & LMN Type :- Upper Cervical Cord vs ALS+

CHIEF COMPLAINTS:-
A 65yr old lady, right handed individual, who is a house wife presented with a chief complaints of 
1.Difficulty in walking since 2yrs
2.weaknes in both upper limbs since 1yr

HOPI
Pt was a/a 2yrs back then she started developing weakness in both lower limbs which was insidious in onset & gradually progressive and is associated with stiffness in limbs with tripps and Falls, around 5 to 6 episodes without Loc. No h/o buckling seen. she also noticed difficulty in wearing chappals in the form of difficulty in insunating toes, holding, Removing feet from the chappals & is associated with slippage of foot wear with her knowledge. So she stopped wearing chappals from then. At the same time she noticed difficulty in getting up from squatting position for which she used to take support from walls & initially with the help of stick she is able to walk as the difficulty progressed she started using walker since past 1yr. 
Since 1yr patient also noticed difficulty in getting up from lying down position so she turns to a side & with the help of hands she Sits on bed. Since 1 yr she noticed difficulty in mixing food & breaking chapathi so her family members used to break chapati into pieces & serve her. She also noticed difficulty in raising arm above head & combing.
Patient attenders noticed minimal thinning of hand muscles since 6mnths.
Patient reports intermittent twitching.over Rt biceps region.
No h/o Tingling, burning, numbness in limbs.
No h/o double vision, Dysphagia, Dysarthria, Nasal regurgitation.
No h/o memory disturbances / altered behaviour,/ seizures/ hallucinations.
No h/o urinary urgency/frequency/ retention.
No h/o bowel & bladder disturbance's.
No electric shock like sensation radiating to leg & no shock like sensation on bending neck.
No h/o palpitation/postural dizziness/ loss of sweating.
No h/o any impairment in vision/ hearing/ speech/ chewing & swallowing.
No h/o wt loss, decreased appetite, 
No h/o trauma In back

PAST HISTORY:-
No significant past history
K/c/o HTN, DM2 since 10yrs

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:- An elderly female who's k/c/o HTN, DM2 presented with chronic progressive Quadriparesis UMN type, LL > UL without HMF,CN,SS,B&B,ANS system involvement.

Anatomy:- Spinal cord - cervical above C5, below Foramen Magnum.

GENERAL PHYSICAL EXAMINATION:-
Pt is conscious/ alert/ cooperative
Facies- Normal
Built- moderate
Nutrition- BMI- 18kg
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 /
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- Slurred however Language function ( syntax, naming, comprehension)
is normal.

CRANIAL NERVES:-
Normal

MOTOR:-
Wasting in thenar & hypothenar muscles of both hand's.
fasciculations seen over biceps.
Minipolymyocponus in both hands +nt
Wartenburg sign +nt


Attitude-
Pt lying supine position with attitude of both lower limbs are externally rotated & 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
Spasticity in all imbs - U/L - Grade 1 ( with froments / activation maneuver)
LL - Grade 2 

POWER-
UPPER LIMB-.                    
                             Rt. Lt
Shoulder
 3/5

Elbow
 Flexion. 4-/5
 Extension. 4-/5

Wrist
 Dorsiflexion. 4-/5 4-/5
 Palmar flexion. 4-/5. 4-/5

Small muscles of both hands - weak
Finger escape sign +nt

LOWER LIMB-                  
                             Rt. Lt
HIP
 Abduction. 4-/5. 4-/5
 Adduction. 4-/5. 4-/5
 Flexion. 4-/5. 4-/5
 Extension. 3 /5. 3/5

KNEE
 Flexion. 4/5 ,4/5
 Extension. 4-/5. 4-/5

ANKLE
 Dorsiflexion. 2/5. 2/5
 Plantar flexion. 4/5. 4/5

Small muscles of foot- weak.

Reflex:-
Brisk DTR in all limbs with b/L extensor plantar.
Pectoral reflex & Scapulohumeral reflex is brisk 
Superficial abdominal. -nt
Deep abdominal +nt


SENSORY:-
spino thalamic
Crude touch,Pain,Temperature are decreased in UL & LL

Post.column:-
Fine touch, Vibration,Proprioception- Decreased in lowerlimbs
Vibration:- 6sec at EHL, 6sec at ankle, 6 sec at ASIS
U/L - 10sec

CEREBELLUM:-
FNF- normal 
HKT- normal 
Nystagmus -nt
Dysdiadochokinesia -nt


GAIT- Slow short stride Wide based cautious gait with help of walker.

MENINGEAL SIGNS:-
Absent

ANS:-
Resting tachycardia, abnormal sweating absent

Functional Diagnosis:- An elderly female with Chronic progressive Quadriparesis ,UMN, LL > UL, Predominantly Motor & CST & without HMF,CN,B&B, ANS Involvement.

Anatomical Diagnosis:-
Upper cervical cord 
Tracts # CST, DORSAL COLUMN'S, 


Pathological diagnosis:-
Chronic & slowly progressive nature- probably Compressive 

.

Etiological diagnosis:-
Cervical Spondylotic Myelopathy 
EMG:- Fasciculations in Rt Trapezius, Biceps 💪, 

Fibrillation in left Tibialis Anterior 

No Tongue Fasciculations 

Incomplete Recruitment in the sampled muscles.

Comments

  1. inquisitivemedmind8 August 2024 at 05:37

    Can high cervical compressive Myelopathy cause hand muscles atrophy??

    ReplyDelete

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