45 year old male with paralysis since 1 year

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Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

PREITY YARLAGADDA

ROLL NO 145

I've 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.

NOV 27TH, 2021.

Case discussion:

A 45 year old male, farmer by occupation came to the OPD with chief complaints of

• Shortness of breath since 1 day
• Decreased urine output since 1 day

History of present illness : 

• The patient was apparently asymptomatic 1 day ago, then he experienced SOB which was in insidious in onset. It aggravated on eating and sitting. No relieving factors.
• The patient also had decreased urine output since 1 day and then developed edema in both lower limbs.
• Since 1 year patient complains of multiple joint pains with restricted movements for which he used ayurvedic medication .
•  H/o trauma to the spine in the field during work 1 year ago, since then the patient is not able to use his left lower limb and right upper limb . 
• H/o a fall 3 months ago when the patient was going to washroom, he had an injury to right elbow and had inability to walk since then.
• The patient was taken to the hospital MRI spine was done. He was diagnosed to have Dislocation of vertebrae and was adviced for surgery but they did not get it done and was bedridden since then. 
• Since last 2 months patient complains of loss of sensations in both lower limbs and stiffning of both upper limbs.
• The patient also complains of urinary incontinence. He is not able to sense fullness of urine since 2 months and was put on foleys .
• Since yesterday there is no urine in foleys and the foleys was removed in a RMP hospital and on attempting to put another foleys, the patient had hematuria and was referred here . 
• No h/o cold , cough, fever , vomitings.
• No h/o abdominal distention or facial edema.

History of past illness:

• Not a k/c/o DM, HTN, epilepsy, asthma.

Personal history :

• Decreased appetite
• Mixed diet
• Increased sleep
• Reduced bowel and bladder movements.
• Addictions - smoker and alcoholic.

General examination :

The patient was examined in a well lit room after taking consent.

• The patient was conscious, coherent and cooperative. He was well oriented to time, place and person.
• Flexion deformites of right upper limb and left lower limb.
• Burn injury is present on right thigh. 
• Edema of feet upto knees. 
• No pallor, icterus, cyanosis , clubbing , lymphadenopathy.
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Vitals :

• Temp - Afebrile
• BP - 70/50 mmHg
• PR - 97/min
• SpO2 - 96% on RA
• GRBS - 114 mg%

Systemic examination :

• CVS - S1, S2 +  
• JVP - raised
• RS - BAE+, NVBS
• P/A - Soft and non tender
• GIT - Bowel sounds+
• 
  
  
  

CNS Examination - 

HMF - Intact

Cranial nerves - Intact

Sensory system - 

• No sensations in B/L lower limbs.
• The patient had 'band like sensation' at the level of T6.
• Crude touch is present upto level of T5-T6.
• Fine touch is present till T2.
• Pain sensation is present upto level T2.
• Vibration                          

                                  R           L     

                 Wrist    Lost      Lost 

                 Elbow      +           +

                    LL      Lost      Lost 

• Proprioception

                                 R            L

                              Lost       Lost

Motor system -

• Tone - Couldn't be elicited as the patient is not able to completely extend the limbs.
• Power -                    R               L

              Upper limbs     4- / 5         4- / 5

              Lower limbs     0 / 5          0 / 5

• Reflexes - 

                              B      T      S      K      A     

                Right -  3+    3+    3+      -       -     

                  Left -  3+    3+     2+     -        -   

            Plantar Right - withdrawl 

            Plantar left - mute 

Reflexes video - https://sairajgovind099.blogspot.com/2021/11/45-year-old-male-with-septic-shock.html

Investigations :

Provisional diagnosis :

SEPTIC SHOCK

Plan of care :

• IV fluids 2 units of NS @ 75ml/hr.
• INJ. Noradrenaline to maintain BP @ 8ml/hr.
• INJ. Lasix 40mg IV BD
• Saline guage dressing for right thigh.
• Protein powder 2tbsp in 100ml milk BD.
• 2 egg whites/day.

Update : 

• The patient had one episode of sudden unresponsiveness with one central pulses and the BP was not recordable. It was relieved with INJ. Noradrenaline 2mg/IV stat. Such episodes are occuring once a day.
• The patient's attenders have been explained about the patient's condition and poor prognosis but they decided to leave against medical advice.
• The patient was discharged on 30-11-2021.

Questions :

1. Why does the patient have band like sensation?

2. How do we manage the repeated falling of BP?