Chief complaints:-

Patient c/o low back pain from 2 weeks.

History of presenting illness

Patient apparently alright 2 weeks back, when he started having low back pain from 2 weeks, insidious onset, gradually
progressive, more on standing for long duration, aggravated following physiotherapy.

h/o pain , sharp type, radiating to both lower limb R>L, insidious onset, gradually progressive, mildly relieved on medications, no
h/o diurnal variation,

h/o neurogenic claudication present, for 300mtrs, now the patient is bed bound for the past 2 days.

h/o difficulty in walking present, h/o difficulty in getting up from squatting position,

No h/o trauma present,

No h/o slippage of chappals present ,

No h/o cotton wool sensations, difficulty in percieving hot and cold sensations,

no h/o bowel complaints, urinary retention since today morning.

no h/o difficulty in rolling over the bed, lifting head ,

no h/o cranial nerve involvement

Past History

known case of and HTN , on medication

no h/o bronchial asthma, TB, T2DM.

Personal History

diet-mixed

appetite-normal,

sleep- disturbed

bowel - normal

Family history:

Not significant

GENERAL EXAMINATION:-

Moderately built and nourished.

T- normal

BP- 120/80 mm HG

RR- 19/min

Pulse- 84/min

GCS- E4V5M6

Pupils- both 3mm equally reactive to light

Cranial nerve examination

CN 1:Intact

CN 2:

Visual acuity: RE 6/6 LE 6/6

Visual fields: Normal

Color vision: Normal

Fundus: Normal

CN 3,4,6 EOM Normal

CN 5- V1 V2 V3 Normal

Sensory: Normal

Motor : Normal

Corneal reflex-

Eye Direct Consensual

present present
Right eye

present present
Left eye

Jaw jerk- Present

CN 7- Normal

CN 8-
 Test Right Left

Rinne AC > BC AC > BC

Weber not lateralised not lateralised

CN 9,10:
Uvula – Midline
Palatal movement- Normal

Gag Reflex- Normal

CN11: Normal

CN12:

Tongue - Bulk - Normal

Deviation - No
POWER:-

tone and bulk-normal

RIGHT LEFT

Shoulder Flexion 5/5 5/5

Extension 5/5 5/5

Adduction 5/5 5/5

Abduction 5/5 5/5

Elbow Flexion 5/5 5/5

Extension 5/5 5/5

Wrist Flexion 5/5 5/5

Extension 5/5 5/5

Hand grip 100% 100%

Hip Flexion 0/5 0/5

Extension 0/5 0/5

Adduction 0/5 0/5

Abduction 0/5 0/5

Knee Flexion 0/5 0/5

Extension 0/5 0/5

Ankle Dorsiflexion 0/5 0/5

Plantar Flexion 0/5 0/5

EHL 0/5 0/5

Reflexes :
Superficial- present
Abdominal reflexes- present
Plantars- mute Bilateral
 Deep Tendon Reflexes : B T S K A

Right - 2+ 2+ 2+ 0+ 0+
Left- 2+ 2+ 2+ 0+ 0+

Sensory system:-

Touch – intact
Rhomberg’s sign- negative
2 point discrimination test- intact
Vibration sense- intact
Joint position sense-

Cerebellar signs:-
Dysdiadochokinesia- absent
Finger-nose test- intact
Finger-nose-finger test- intact
Knee-heel-shin test- intact
Pendular knee jerk- absent
Rebound phenomenon- absent

Other system examination:-

Cardio-vascular system- S1,S2+

Respiratory system- NVBS+, BE+
Per abdomen- soft

CT/MRI:- L3 L4 upmigrated central disc compressing the cauda equina

DIAGNOSIS- L3 L4 upmigrated central disc compressing the cauda equina with cauda equina
syndrome with bladder involvement.

Case discussed with Dr. Ramesh Chandra (HOD

neurosurgery):-

Advice:- Plan for decompressive laminectomy and discectomy