60 Y/M with sudden lower limb weakness with bowel and bladder incompetence

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A 60 Y/M , previously a autodriver came with chief complaints of B/L lowerlimb swelling B/L lower limb weakness and 

decreased speech output since 4 days

bowel and bladder incontinence since 4 days

HOPI: patient was apparantly asymptomatic 4 days ago then on tuesday morning when he developed bilateral lower limb swelling which is insidious in onset, intermitten ,not pitying type H/o dragging type of pain from proximal to distal , continuous aggravated on walking(impairing him to walk).

H/o bowel and bladder incontinence since 4 days, started on tuesday afternoon without his conscience , 4-5 times  last 4 days.

H/o low speech output in volume and intensity from tuesday evening.

4 days ago,he slept and tried to wakeup in the morning at 5 o clock  to go to bathroom, he cannot able to walk as he having dragging type of pain stayed in bed, in afternoon he started to pass stool and urine on bed without his conscience, his wife also complaints from evening , he cannot able to shout , low volume and cannot talk as efficiently previous day ,they went to a local hospital , they referred to our centre.

Past history:

Not a clinical case of dm,htn, epilepsy , asthma ,tb.

No h/o falls and previous hospital admissions.

Personal history:

5 months ago he quit his job due to economical constraints and their children living far away , he and his wife living in a house and his wife works for him. 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative , well oriented to time place and person

moderately built and nourished

He is little bit drowsy

he responds slowly vocally and in actions

MMSE :13/30

On examination: 

BP: 180/90 mm hg in right hant sitting position after 4 hours his bp came down to 150/90mmhg

PR : 94bpm

temperature :afebrile

Rr-16cpm

SPo2 - 98@ Ra

grbs -131 mg/dl

no pallor,icteris,cyanosis,clubbing,lymphadenopathy and pedal edema

On examination

SYSTEMIC EXAMINATION:

CNS EXAMINATION: CNS EXAMINATION

1.HIGHER MENTAL FUNCTIONS:

Conscious, coherent, cooperative

Appearence and behaviour:

Emotionally stable

Recent- intact

,immediate- impaired( cannot recall what he ate yesterday

remote memory ( intact)

Speech: comprehension normal, fluency reduced, no repetition, low volume ,low intensity

Right handed individual

2.CRANIAL NERVE EXAMINATION

Olfactory: normal

Optic: 

visual field: ?, gaze preference presnt

Visual acuity: CF

Colour vision : cannot be assessed

Pupil: NSRL

3,4,6: normal ocular motility in all directions.

Accommodation PRESENT

Light reflex PRESNT

Trigeminal: normal sensory ,motor

Facial nerve: 

Forehead wrinkling present

Able to close hIS eyes

Able to blow ( fully)

Angle of mouth NO deviation

8nerve: no hearing impairment ,no nystagmus

9 and 10 nerve:normal

11: scm and trapezius- normal 

12: no deviation of tongue, no fasiculations

IMPRESSION: Normal

MOTOR EXAMINATION:

Attitude: in supine position,both upper and lower limb extended 

Bradykinesia noted

Tone:           

          Right            left

Ul:

flexors :normal ( slightly increased) normal           

Extensors :  normal  normal

LL

flexors and extensors normal tone

Power:          right             left

Shoulder: 

 flexion  :     4/5               4/5

 Extension  4/5           4/5

Abduction  5/5        5/5

Adduction   5/5          5/5

Internal rotation  5/5    5/5

External rotation    5/5    5/5

Elbow:

Flexion:5/5

Extension:5/5

Wrist:5/5

Flexion:5/5

Extension:5/5

Abduction :5/5

adduction:5/5

SUPERFICIAL REFLEXES

Conjunctival   N       N

Abdominal: present present

Plantar:         extensor response

DEEP REFLEXES:

Biceps :        2+        2+

Triceps :      2+         2+

Knee :     2+     2+

Ankle:     1+  1+

No clonus

SENSORY FUNCTIONS

SPINOTHALAMIC TRACT

Pain , temperature ,pressure- intact in all limb.

Posterior column:

Fine touch - + ,+

 vibration - impaired

 proprioception - intact

sensory ataxia - present

CEREBELLAR FUNCTIONS:

Titubation: absent

Nystagmus: absent

Dysmetria:absent

Dysadeadochokinesia: absent

Intention tremor:absent

Impression:no signs of cerebellar dysfunction.

ANS: postural drop - absent 

pupils - reacting to light

CVS EXAMINATION

NO jvp raised

s1 s2 present 

ESM present

RESPIRATORY EXAMINATION

TRACHEA CENTRAL

NVBS,No added sounds

INVESTIGATIONS:

TREATMENT:

AMLODIPINE 5MGPO/OD

LASIX 20MG PO/BD

POTCHLOR 10ML/PO/BD ×5DAYS