Case of 80 year old male with upper limb and lower limb weakness

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Neha Tipparaju 

Roll no. 100 

Case of an 80 year old male with Upper and Lower limb weakness 

My case is of an 80 year old male,  who was a shepherd by occupation and a resident of Miryalguda, came to the OPD with chief complaints of neck pain and weakness of upper and lower limbs since 3 days.

Timeline of events and history of presenting illness: 

5 years ago: Patient was a shepherd. He used to leave at 6 am and come back at around 4 pm. He stopped working on the advice of his family as he was getting tired very easily and had frequent falls in the field. 

Since then, he stays at home all day and was able to look after himself in terms of brushing, bathing, feeding etc. 

3 days ago (1/2/2022): Patient had his dinner around 8 pm and retired to bed. He then suddenly fell off the bed and complained of neck pain and inability to use both his upper and lower limbs. He was taken to the local RMP who checked his blood pressure and told him he was hypertensive. Unknown medication was given.

The weakness was not a/w loss of consciousness, slurring of speech, drooping of mouth, seizures, tongue bite or frothing of mouth, difficulty in swallowing.

No complaints of any headache, vomitings, chest pain, palpitations and syncopal attacks. 

No shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain or burning micturition. 

Since 2 days, the patient has slurring of speech and non productive cough. 

Past history: 

No similar episodes in the past. 

Not a known case of diabetes mellitus, asthma, epilepsy, coronary artery disease. 

No surgical or drug history

Personal history:

They take a mixed diet, appetite is normal, bowel and bladder are regular, sleep is adequate. He was an occasional toddy drinker, 90 mL during festivals. Stopped 5 years back. Does not smoke. No known allergies. 

Family history: 

No similar complaints in the family  

Patient is examined in a well lit room after obtaining informed consent. She is conscious, coherent and cooperative, well oriented to time, place and personn, moderately built and nourished. 

On  General Examination: 

Pallor: Present

Icterus, cyanosis, clubbing, koilonychia, generalized lymphadenopathy or edema are not observed. 

Vitals:

Temp.- Afebrile

BP- 190/100 mmHg

PR- 92 bpm

RR- 21 cpm

SpO2- 96%

GRBS- 144 mg/dL 

CNS: 

Higher mental functions:

Oriented to time,place,person

Memory : recent, remote intact

Speech: Not understandable

No delusions or hallucinations

Cranial nerves: 

1- not tested

2- binocular vision: decreased in right eye due to senile immature cataract

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face)

 

7-Normal, wrinking of forehead seen, able to blow up cheeks

8- Normal hearing

9,10,11,12-normal. Gag reflex is normal.

Motor examination:

Tone - decreased in upper limbs, normal in lower limbs 

Power 

1/5 in  lower limbs 

0/5 in  upper limbs

Reflexes :

Biceps: Right, left: 

Triceps: 

Supinator: Right, left: 

Knee: Right:  2+

           Left: 3+ 

Ankle: Right: 1+ 

             Left: 2+ 

Plantars: Flexion of leg at knee joint is seen. Mute 

Sensory examination:

Deep pain is absent below nipple area

Cerebellum examination:

Able to do finger nose test.

No dysdiadokinesia 

No rebound tenderness 

Autonomic Nervous System:

No postural hypotension 

No bladder and bowel incontinence 

No sweating abnormalities

Meningeal signs:

No meningal signs like Brudzinski or Kernig sign were positive 

Gait: did not walk due to weakness

CVS: S1 S2+ no murmurs heard.

Respiratory system- Bilateral air entry+ ,normal vesicular breath sounds-heard. 

Abdominal: Soft, non tender, no distension, umbilicus is central and inverted,no scars, no sinuses, hernial orifices free. 

INVESTIGATIONS:-

HEMOGRAM-

HB:- 8.3GM/DL

TC:- 5,300

N/L/E /M :- 95/ 02/01/02

PCV :- 25.6

MCV- 80.5

MCH:- 26.1

MCHC:- 32.4

RBC :- 3.18

PLATELETS:- 4.72

NORMOCYTIC NORMOCHROMIC ANEMIA WITH NEUTROPHILIC LEUCOCYTOSIS.

COMPLETE URINE EXAMINATION:- 

PUS CELLS- 3-4

EPITHELIAL CELLS - 2-3

ALBUMIN:- TRACE (2.8)

SUGARS:- NIL

RBS- 162MG/DL

FBS:- 144MG/DL

PLBS:- 126MG/DL

LFT:- 

TB:- 0.55

DB:- 0.18

AST:- 19

ALT:- 10

ALP:- 135

TOTAL PROTEIN:- 5.7

A/ G RATIO:- 0.96

RFT:- 

BLOOD UREA -52

SERUM CREATININE - 0.9

Na:- 137

K:- 5.8

Cl:- 102

HBA1C:- 6.6 %

FASTING LIPID PROFILE:-

TOTAL CHOLESTROL:- 112MG/DL

TRIGLYCERIDES:- 174 MG/DL

HDL CHOLESTEROL:- 30MG/DL

LDL CHOLESTROL:- 89 MG/DL

VLDL:- 35MG/DL

MRI: 

IMPRESSION:- 

1)  MODERATE TO SEVERE CERVICAL SPONDYLOSIS AT MULTILEVEL C2-C3 , C3-C4 , C4-C5 & C5-C6 LEVEL WITH COMPRESSIVE MYELOPATHY CHANGES AND SPINAL CANAL STENOSIS

2) NEURAL IMPRINGEMENT AT C4-C5 , C5-C6 LEVELS.

Xrays: 

USG report: 

Bilateral Grade 2 Renal Parenchymal Disease with Simple cortical cyst.

Chest: Mild pleural effusion on right

Mild pleural effusion on left with Consolidation in peripheral lung parenchyma

Doppler:

Ejection Fraction:- 48%

Mild LV dysfunction

Mild diastolic dysfunction  ,

Mild PAH

DILATED RA  / LA/ RVH

Provisional diagnosis:

? Compressive myelopathy 

Treatment:

1) IV FLUIDS @75 ml/hr

2)  CERVICAL HARD COLLAR

3) TAB AMLONG 5MG PO/OD

4) TAB PAN 40MG PO/OD

5) TAB ZOFER 4MG PO/ SOS

6) BP/ PR/ RR / TEMP CHARTING

7) STRICT IPO CHARTING

8) INJ OPTINEURON 1 AMP IN 100ML NS / IV / OD

Pleural tap was advised.