35 year old male with traumatic paraplegia and inability to void bladder

June 12, 2023

35 year old male with traumatic paraplegia and inability to void bladder

** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

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I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings, Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

CASE SHEET

This is the case of a 35 year old gentlemen from West Bengal, fish seller by occupation who presented with traumatic paraplegia and inability to void bladder since 4 months.

History of presenting illness:

He was asymptomatic 4 months ago when on Holi, 7th March 2023 the patient met with an accident under the influence of alcohol and fell off of his bike and sustained spinal cord injuries

MRI of spine was done on the same day and revealed the following:

Hyperintensity on C3 to C5 level.

The patient described inability to move all 4 limbs on the Day of the accident along with bladder incontinence, inability to speak.

Patient regained ability to speak, and facial movements on the next day after accident.

Foley's catheterization was done which still is present.

NCS of day of accident reveals axonopathic neuropathy in all limbs.

In 1.5 months patient regained sensation and movement in both upper limbs gradually starting from digits to shoulders.

Weakness in all limbs still persists. There is inability to extend digits completely.

Patient reports numbing and tingling sensation in digits which is releived on pulling or stretching fingers forcefully.

Patient has regained sensation of touch and pressure over lower limb but cannot sense pain.

Patient complained of dull aching pain over the left hip on walking with support and releived on resting. Due to this pain patient lies down while flexing left leg at the knee to provide himself some releif

Since 1 month, the patient is also complaining of the fullness of his abdomen describing an uncomfortable sensation similar to one after over eating.

At present, the patient is unable to initiate micturition and is unable to completely evacuate urine even though the patient feels the fullness of his bladder.

The patient also complains of constipation and describes that his last bowel movements were 3 days ago. The stool is hard and passing stool is painful. The patient is unable to evacuate the bowel without a laxative. He is taking Lactulose solution to pass stools

History of past illness: Not a known case of DM, HTN, TB, epilepsy

Drug history:

Personal history:

Diet: Mixed

Appetite: Normal

Bladder Movements: inability to initiate micturition and complete evacuation of urine. However the sensation of fullness of the bladder is felt . Foley's catheter was placed at time of accident and is still needed.

Bowel Movents: Constipated, requires a laxative to evacuate bowels. The last stool was passed 3 days ago

Addictions: Alcoholic, consumes 125 ml of Alcohol on the days he gets the money. Habit formed in last 5 years

Sleep is reduced and disturbed. Difficulty in both falling asleep and remaining asleep. Before the accident patient slept continuously for 8 hours

Family history: not significant

General examination:

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: present

Koilonychia: absent

Lymphadenopathy: absent

Edema: absent

Vitals:

Temperature: afebrile

Respiratory rate: 15 per minute

Pulse : 76bpm

Blood pressure: 130/90 mm of Hg

CVS examination:

Respiratory system examination:

CNS Examination

Higher Mental Functions: Normal speech and language

Memory: Both short term and long term memory intact. Can recollect recent and remote incidents

No delusions or hallucinations

Cranial nerve examination:

I : Intact bilaterally

III, IV, VI : Extraocular movements free and full bilaterally, direct and indirect light reflex present.

Accommodation reflex present bilaterally

V : Intact bilaterally

VII:Intact bilaterally

VIII: No nystagmus, intact bilaterally

IX,X : Intact bilaterally

XII : Intact bilaterally

Motor System examination

Bulk : reduced in upper and lower limbs bilaterally

Power : Reduced Power of Shoulder , Elbow , Wrist , Smalll muscle of hand and hand grip bilaterally and Hip , knee , ankle , small muscles of foot bilaterally

Muscle tone : Rigidity observed in both upper limbs.

Reflexes are exaggerated in biceps , triceps , knee jerk , ankle jerk bilaterally.

Sensory system examination

Upper limb : Normal

Lower limb: Crude touch , temperature , fine touch ,vibration sensation present bilaterally and Pain sensation is absent bilaterally

Cerebellar signs : Normal

Gait : Spastic gait

Clonus elicited on extension at the ankle bilaterally

Prior investigations

MRI ON 7/3/23