Case Presentation

Parvathi V
• Gopalan
• 52 year old male from Edakkara, Malappuram
• Manual laborer
Presenting complaints
• Diffuse body pain for 3 months
• Loss of sensation of both lower limbs for 12 days
• Weakness of both lower limbs for 10 days
• Urinary and bowel incontinence for 10 days
History of present illness
• The patient developed a dull, aching pain all over the body 3 months
back
• He was not able to go to work because of the severity of pain
• There are no aggravating or relieving factors
• He was admitted in hospital twice, for 6 days each for the pain but it
was not relieved
• 3 weeks ago, the patients started feeling numbness of the lower
limbs. It was initially only present at the foot but later progressed to
involve both lower limbs.
• After the involvement of both lower limbs, patient complains of
reduced sensation at the abdomen
• 2 days later, the patient noticed weakness of the right lower limb
which started as inability to hold the chappal and it progressed such
that the patient had to drag his right foot while walking.
• He then started developing weakness of the left limb which
progressed to involve the whole limb within 2 days.
• Now, the patient is completely unable to move both lower limbs and
is not able to appreciate sensation below the chest
• The patient also complains of urinary and fecal incontinence over the
past 10 days
• Initially he only had dribbling of urine when he tried to urinate but
now he is not able to control passage of urine
• Bladder is now catheterised
• For the past 5 days he is having left sided chest pain which aggravates
on inspiration. Associated with breathlessness and cough without
expectoration.
• He also gives history of weight loss for the past 3 months
• No history of weakness of upper limb. No history of fever, hemoptysis,
trauma, nausea, vomiting, headache, loss of consciousness, abnormal
movements or seizures. No similar previous episodes of weakness or
root pain
Past history
• History of pulmonary tuberculosis 8 years back for which he took
medication for 6 months and was found sputum negative at the end
of treatment
• History of diabetes mellitus for the past 6 years for which he was
taking mediation, but stopped when blood sugar became normal.
Medication has been restarted now
• No history of hypertension, cardiac disease or bronchial asthma
Family History
• No history of diabetes or hypertension in the family
• No history of similar illness in the family

Personal History
• Mixed diet
• Appetite is normal
• Sleep is normal
• Bowel habits disturbed due to incontinence
• Bladder is catheterised
• He is a smoker for the past 40 years and smokes 25 cigarettes per day.
He stopped smoking a month back. Pack years= 50
• He also consumed 200mL of brandy everyday for the past 40 years.
He stopped drinking 3 months ago.

Socioeconomic History
• Lives in a tiled house with good sanitation facility
• Family has 2 working members, but he has not gone for work for past
2 months
General examination
• Conscious, oriented and cooperative
• Poorly built and nourished
• No pallor, icterus, cyanosis or lymphadenopathy
• Clubbing present
• Bilateral pitting edema present
• No thyroid swelling, no varicose veins
• Patient is dyspneic and wearing an oxygen mask, Intercostal
retractions present
Vitals
• Pulse - 91 / min , regular rhythm , normal volume and character , no
vessel wall thickening, all peripheral pulses palpable
• Respiratory rate - 20/ min , regular, abdominothoracic
• Blood pressure -90/ 60 mm of Hg in right arm supine position
• Afebrile to touch
Nervous sytem examination
• Higher mental functions
• Conscious and oriented in time place and person
• He is cooperative and well dressed
• He is attentive with normal speech and comprehension
• Memory is normal
• No delusions, hallucinations
• Normal mental and emotional state
Examination of cranial nerves
Right Left

I-Olfactory nerve- sense of Normal Normal

smell
II-Optic nerve

Visual acuity 6/6 6/6

Visual Field Normal Normal

Colour vision Normal Normal

III,IV,VI-Oculomotor, Right Left
trochlear, abducent nerve

Extraocular movements Full range in all directions Full range in all directions

Squint / diplopia Absent Absent

Ptosis Absent Absent

Pupil (size and shape) Normal Normal

Reaction to light: Brisk Brisk

Direct
Indirect

Accommodation Normal Normal

V-Trigeminal Nerve Right Left

Motor:
Clenching of teeth Equally prominent on both sides
Opening of mouth No deviation of jaw

Reflexes Corneal and conjunctival reflex Corneal and conjunctival

present reflexes present
Jaw jerk absent Jaw jerk absent

Sensations Normal Normal

Touch, pain and temperature
VII-Facial nerve Right Left
MOTOR- Present Present
Wrinkling of forehead

Nasolabial fold Present Present

Whistling Able to whistle

Inflating mouth and blowing Able to inflate cheeks and blow out air against resistance

Closure of eyelids Normal Normal

SENSORY- Normal Normal

Taste on anterior 2/3rd of tongue

History of hyperacusis Absent

VIII-Vestibulocochlear Right Left
nerve
Tuning fork tests-
Rinne test Positive Positive

Weber test Centralized

Absolute bone conduction Normal Normal

Abnormal auditory sensations-

Tinnitus Absent
Auditory hallucinations Absent

Abnormal vestibular function-

Nystagmus Absent
IX-Glossopharyngeal nerve Right Left
Gag reflex Present Present

Palatal reflex Present Present

Taste on posterior 1/3rd of tongue Not tested

X-Vagus nerve
Nasal tone of voice Absent

Position of uvula Central

Movement of palate Normal

No history of nasal regurgitation

XI-Spinal accessory nerve Right Left
Trapezius Can shrug shoulders against Can shrug shoulders against
resistance resistance
Sternocleidomastoid Can turn face against resistance Can turn face against
resistance
XII-Hypoglossal nerve
Protrusion of tongue No deviation

Wasting of tongue Absent

Fasiculations/ fibrillations of tongue Absent

Examination of motor system
1) Bulk of muscles
Upper limb Right (cm) Left(cm)
Arm 19 19

Forearm 20 19

Lower limb
Thigh 32 32

Calf 27 27
2. Tone of muscles

Right Left

Upper limb Normal Normal

Lower limb Decreased Decreased

3) Power
Right Left
Upper limb
Shoulder abduction 5 5
Shoulder adduction 5 5
Elbow flexion 5 5
Elbow extension 5 5
Supination 5 5
Pronation 5 5
Wrist flexion 5 5
Wrist extension 5 5
Lower limb
Hip flexion 0 0
Hip extension 0 0
Knee flexion 0 0
Knee extension 0 0
Ankle dorsiflexion 0 0
Ankle plantar flexion 0 0
4) Examination of reflexes

Superficial Reflexes Right Left

Corneal reflex Present Present
Conjunctival reflex Present Present
Babinski sign Absent Absent
Superficial abdominal reflex Absent Absent
Anal reflex Not tested
Bulbocavernous reflex Not tested
Cremasteric reflex Not tested
Deep tendon reflexes Right Left
Biceps jerk Present Present

Supinator jerk Present Present

Triceps jerk Present Present

Knee jerk Absent Absent

Ankle jerk Absent Absent

Jaw jerk Absent

Clonus
Patellar clonus Absent Absent

Ankle clonus Absent Absent

5) Tests for coordination

• Upper limb-
No dysdiadokokinesia
Finger nose test is normal
• Lower limb-
Heel knee test -not done
Tandem walking -not done
Examination of sensory system
Superficial
Lower limbs Upper limbs
sensations
Crude touch Absent below T4 on both sides Present on both sides
Pain Absent below T4 on both sides Present on both sides
Temperature Absent below T4 on both sides Present on both sides

Other sensations
Joint sense Absent in both lower limbs Present on both sides
Position sense Absent in both lower limbs Present on both sides
Fine touch Not tested Present on both sides
Vibration sense Absent in both lower limbs Present on both sides
Tactile localization Not done Present on both sides
Two point Not done Present on both sides
discrimination
Romberg test Not done
No deformities of skull and spine
No neck stiffness or signs of meningeal irritation.
Respiratory system examination
• INSPECTION:
• Shape of chest : bilaterally symmetrical
• Trachea – appears to be central
• Apex beat – not visible
• Chest wall movements – appears reduced on left side
• Normal skin, no dilated veins, scars or visible pulsations.
• Lower intercostal retractions present
• PALPATION:
• Trachea – central
• Apex beat – left 5th intercostal space, 1 cm medial to the midclavicular
line.
• Chest expansion- 3 cm ,is reduced on left side.
• Tactile vocal fremitus – Decreased in left axillary, infraaxillary and
infrascapular regions
• No intercostal narrowing
• PERCUSSION
• Percussion on right side- normal resonant note
• Stony dull percussion on left axillary, infraaxillary and infrascapular areas
• Liver dullness at right 5th ICS in midclavicular line

• AUSCULTATION:
• Reduced intensity of breath sounds heard in left axillary, infraaxillary
and infrascapular areas
• Normal vesicular breath sounds heard in all other lung areas
• No added sounds
• Vocal resonance- decreased in left axillary, infraaxillary and infra
scapular areas
• Cardiovascular system
• JVP not elevated
• Apex beat palpable at 5th ICS 1 cm medial to midclavicular line
• First and second heart sounds heard normal
• No murmurs

• Gastrointestinal system
• Oral cavity is normal
• No hepatosplenomegaly
• No palpable masses or tenderness
Summary
52 year old male who is a diabetic, chronic smoker and alcoholic with past
history of pulmonary tuberculosis now presented with diffuse body ache
for the past 3 months, weakness and loss of sensation of both lower limbs
for past 12 days and bladder and bowel incontinence since 10 days. The
weakness of lower limbs progressed in 2 days and is associated with
numbness below the chest.
On examination, clubbing and bilateral pitting edema present. Cranial
nerves within normal limits. All sensations below T4 were absent, grade 0
power in both lower limbs. Extensor plantar reflex, superficial abdominal
reflex, knee jerk and ankle jerk absent. On respiratory system examination,
chest movements decreased on left side. On percussion stony dull note was
obtained in left axillary, infraaxillary and infrascapular areas. Tactile vocal
fremitus, vocal resonance and breath sounds decreased in left axillary,
infraaxillary and infrascapular areas.
Diagnosis
UMN type of paraplegia in spinal shock with sensory level at T4
Vertebral level at T2
With left sided pleural effusion
• Etiology- secondary metastasis from bronchogenic carcinoma