A CASE OF POST TRAUMATIC QUADRIPLEGIA WITH LMN TYPE BLADDER PRESENTED

  • The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent. 


  • Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.


  • This E-log also reflects my patient's centered online learning portfolio.



I have 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 class data including history, clinical findings, investigations and come up with a diagnosis and providing treatment best to our skills and wisdom.



A 36yr old patient who is a fish seller by profession and a resident of West Bengal presented to the casualty with complaints of loss of sensation and weakness in the lower limbs and retention of urine 

Date of Admission: 11/06/23


CHIEF COMPLAINTS 


➤ Weakness in B/L Upper and Lower limbs since 3 months . 


➤ Retention of urine since 3 months . 


➤ Decreased sensation of B/L lower limbs since 3 months . 


HISTORY OF PRESENTING ILLNESS


Patient was apparently asymptomatic 3 months ago . Then he met with a RTA (bike accident ) on 7/3/23 and sustained injuries to the back and the head . Since then the patient had B/L weakness of upper and lower limbs alongwith retention of urine.

Patient had h/o loss of consciousness since 1 day following the fall from the bike . 

No h/o involuntary movements or vomitting.


HISTORY OF PAST ILLNESS 

 

➤ Not a k/c/o diabetes mellitus, HTN , TB epilepsy , asthma ,CAD , thyroid disorders.


PERSONAL HISTORY


➤Occupation: Fish seller 


➤Patient is married .


➤Patient takes a mixed diet and has a normal appetite. 


➤Sleep : Regular 


➤Bowel movements are normal , unable to pass urine since 3 months . 


➤No known allergies .


➤ Addictions -       Alcohol : 3-4 quarters/day                                                     since 6 yrs . 

                                  Pan 


➤ No h/o surgery or blood transfusion.



FAMILY HISTORY 


Not significant .


GENERAL EXAMINATION


➤Pallor : not seen 


➤Icterus : not seen 


➤Cyanosis : not seen 


➤Clubbing : not seen 


➤Lymphadenopathy : not seen 


➤Edema : not seen . 


VITALS 


➤ Afebrile 


➤PR : 88 beats per minute


➤BP : 100/70 mm Hg


➤RR : 18 cycles per minute


➤SpO2 : 96% in room air


➤ GRBS : 103 mg/dl 


SYSTEMIC EXAMINATION


CARDIOVASCULAR SYSTEM EXAMINATION


➤s1 and s2 heard


➤Thrills absent.,


➤No cardiac murmurs


 RESPIRATORY SYSTEM


➤Normal vesicular breath sounds heard.


➤Bilateral air entry present


➤Trachea is in midline.


➤ Breath sounds - vesicular 


➤ Additional sounds - Rhonchi heard 


ABDOMINAL EXAMINATION


INSPECTION


➤Shape - Scaphoid 


➤Equal movements in all the quadrants.


➤No visible pulsation, dilated veins and localized swellings.


PALPATION


➤Liver , spleen not palpable.


➤ No tenderness . 


CENTRAL NERVOUS SYSTEM EXAMINATION


➤Conscious and coherent 


➤Speech : Normal 


➤No signs of meningeal irritation 


➤ Cranial nerves intact .


➤ Motor system 


       Power   Rt.        Lt 

              U/L.  5/5      5/5

              L/L.   4/5.     4/5      


        Tone 

              U/L.  Hyper   Hyper 

              L/L.   Hyper  Hyper 


GCS - E4 V5 M6


Reflexes. B T. S. K. A. plantar

   

         Lt: 3+. 3+. 3+. 4+. 3+. extensor 

         Rt: 3+. 3+. 3+. 4+. 3+. extensor 


 Pupils : NS NR           


 PROVISIONAL DIAGNOSIS : POST TRAUMATIC QUADRIPLEGIA WITH LMN TYPE BLADDER .  


INVESTIGATIONS

 

ECG



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