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 a diagnosis and treatment plan.
After going through the patient details as given by our Intern Mam through the following link.
https://vaish7.blogspot.com/2020/05/medicine.html?m=1
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As of coming to the I want to keep the chief complaints in a PRIORITY ORDER
1)Weakness of bilateral lower limbs since 5 days complaints of tingling and numbness
2)Sudden fall while going for urination.
3)Scrotal abscess since 20 days(incision and drainage 10 days back)
4)Gluteal abscess since 5 months(operated 5 months back)
5)Vomitings 5 days back 3-4 non projectile,non bilious,food particles is content
My interpretation of the chief complaints
1)Weakness of bilateral lower limbs since 5 days complaints of tingling and numbness.
Weakness of the bilateral lower limbs may be due to many reasons like
- Motor lesions
- Inflammation of the muscle
Points in clinical findings:
1)Hypotonia
Can be primarily be due to a Lower motor neuron lesion
2)Power of lower limbs Rt 2/5 Lt 0/5
3)Plantar reflexes or babinski reflex present in both the lower limbs which indicates a Upper motor lesion
4)Hyperreflexia in Rt lower limb a feature of Upper motor lesion.
5)ankle clonus in rt lower limb which is a feature of upper motor lesion
Provisional diagnosis of the bilateral lower limb weakness by correlating the Clinical examination results and history of the patient:
1) A 23yr old male patient reported to the OPD with chief complaints of Weakness of bilateral lower limbs since 5 days complaints of tingling and numbness.
2)Sudden fall while going for urination.
3)On examination there was B/L Hypotonia , Reduced power of the limbs Rt limb 2/5 Lt limb 0/5(complete paralysis),Hyperreflxia in Rt lower limb , ankle clonus in rt lower limb indicate a Upper motor neuron lesion in rt lower limb ...Whereas hypotonia , complete paralysis of the Lt lower limb indicate a lower motor lesion in Lt lower limb.
Abnormal findings in the Investigations :
1) Elevated liver enzymes SGOT,SGPT
2)Elevated ESR(may be owing to the inflammation)
3)Reduced lymphocyte count'
4)Abdominal X ray showing psoas abscess
5)CXR Showing Multiple nodules in pulmonary apices
MRI Images:
There is significant enhancement which represents meningeal enhancement or exudates and ring enchancing lesions in rt and left cerebral hemispheres.
Diagnosis:
Paraparesis with L4,L5infective spondylodiscitis with left psoas abscess with ring enhancing lesions in right and left cerebral hemispheres with multiple nodules in pulmonary apices suggesting of Disseminated tuberculosis with healing ulcer in right gluteal region secondary to drained gluteal abscess with pyocele left side operated ( 10 days back).
Differential diagnosis:
Pott Disease (Tuberculous Spondylitis)
1)Spinal TB is usually secondary to hematogenous spread from a primary site of infection (most commonly the lungs).
2)ESR >20mm/hr. In this case it is 45mm/1hr
2)Cold abscess formation down along the psoas muscle, Petit's triangle, Scarpa's triangle, or the gluteal region is common.The patient in this case has gluteal abscess.
3)The initial compression in TB is secondary to vertebral body collapse, leading to anterior spinal tract involvement (exaggerated deep tendon reflexes and Babinski sign, further progression on to UMN-type motor deficit).
4)As the Patient has got Paraparesis with L4,L5infective spondylodiscitis with left psoas abscess I strongly think this case to be Tuberculous Spondylitis
5) Hence I adivce a Gadolinium enchanced MRI to confirm this.
6)I also a advice a C-Reactive protein test.
TREATMENT GIVEN:
T.ATT 3 tabs/day fdc
T.Benadon 40mg/od
T.pregabalin 75mg/po/h/s
OINT.MEGAHEAL FOR LOCAL APPLICATION
SITZ BATH WITH BETADINE TID
FREQUENT CHANGE OF POSITION
A point to ADD regarding the elevated Liver enzymes.
-There is elevated liver enzymes in the investigations done , this may be primarly due to two causes
- Due to the ATT treatment recieved,drugs like Rifampicin lead to a elevated liver enzymes
- Since this is a case of Disseminated tuberculosis the mycobacterium tuberculosis may also have affected the liver leading to rise in liver enzymes.
My Questions :
1Q)The patient has rt lower limb Hypotonia but has ankle clonus and as well in the left lower limb he has 0/5 power but still he has got babinski sign positive.Why?
2Q)
In the chief complaint it is mentioned that he had gluteal abscess 5 months back but the etiology to the gluteal abscess was not asked in the past history and neither past history of TB was asked.So can we presume that gluteal abscess was caused by some other bacterial infection like staphylococcus aureus and can we link the Staph infection to spondylodiscitis ?? Because the most common bacteria causing spondylodiscitis is staph.He has not got any symptoms related to TB like fever,Cough ,Shortness of breath even though he has active tuberculosis infection according to the Chest X ray.
