General medicine case 6

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 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

A 45 yr old female patient housewife by occupation presented to the opd with weakness of lower limb since 3 months and inability to walk since one and half month complaints of  pain and inability to extend her right lower limb since one and half month

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 18 yrs back then she noticed a small swelling in the neck region and which gradually increased in size 3 months ago .

 She was having difficulty in positioning of her feet while walking and even had slippage of footwear.2 months ago she slipped off from the bathroom and Fractured her right ankle joint  for which she recieved treatment in local hospital. 

1 month ago prior to Hospital admission patient lost ability to walk and she was using wheelchair . Patient complaints of upper and lower back pain radiating it to hip joints with stiffness of muscles of inner part ofboth the thighs associated with dragging type of pain and radiating to the lower part of inner thigh more while stretching her lower limbs and more on right side . Patient also complaints that she was unable to lie down in supine position and she is unable to extend her right lower limb completely and her lower limbs have become thinner as compared to 2 months ago.

Patient also gave history of constipation and passing of bloody stools when straining to pass hard stools and she also gives history of recent weight loss of 1 to 2 kg in last 2 months with lower limbs becoming thinner than before

PAST HISTORY 
Patient had similar complaints of lower back ache radiating to hip joint since 1 and half yr back and she has been using over the counter drugs  to relieve her pain. Patient had gall stone removal surgery 6 yrs back

PERSONAL HISTORY
Appetite is normal she takes mixed diet 
Bowel and bladder movements-  she has 
constipation
 Sleep is not adequate due to pain since 2 months
 Addictions- patient had the habit of chewing paan 2 per day past  6 yrs
 
GENERAL PHYSICAL EXAMINATION
Patient is conscious,  coherant and  cooperative and she is well oriented to time place and person 
Pallor present
No icterus v, cyanosis, clubbing, generalized lymphadenopathy 

VITALS
Temperature - afebrile
Blood pressure- 100/70mmHg
PR-78bpm
Spo2- 99% at room air 
GRBS- 110mg/dl

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 

Ausculation:

S1 ,S2 Heard


RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breath sounds - heard

No added sounds


PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

CNS EXAMINATION

Patient is conscious, higher mental function are intact and speech is intact signs of meningeal irritation are absent 

Patient's attener gave the history of delayed responseto warm temperature when they placed a cup of hot tea on her ankle

Proprioception lost upto hip joint.On palpation stiffening of muscles of medial and posterior compartments of both thighs. No spin tenderness present .


• Surgery opinion was taken for neck swelling.USG and FNAC of neck was advised

•orthopedic advice was taken for secondary deposit in sacral and lumbar region with a pathological collapse at T12 seen in MRI


INVESTIGATIONS



                      

                         
                   

               

                     

                 


    

                                    




 


                                                                                                                                                                                     
                                                                                                                                                                                     Diagnosis :-  compressive  myelopathy     secondary to vertebral metastasis secondary to papillary carcinoma of thyroid

Treatment
Tab ultracet po/TOD
Tab mvt
Tab pantop
Tab pregaba 150 mg po/HS
Tab myospaz 4mg PO/BD
Tab amitriptyline 25 mg PO/HS


 Total Thyroidectomy was done other hospital and radiotherapy is being planned in our hospital in month of December

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