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45 yr old female with paraplegia

This is 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 patients’ clinical problems with collective current best evidence-based inputs. 

A 45 year old female, resident of miryalaguda, farmer by occupation was presented to the  casualty with chief complaint of

CHIEF COMPLAINTS:

  • Abdominal, tightness and distension  since 1 day
  • Decreased sensation and weakness  in both legs
  • Decreased urine output 
HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 1 year ago when she developed fever and severe stabbing type of pain in the back for which she visited a hospital in khammam, where she was told to have a spinal cord problem and that she needed a surgery, but due to covid situations and lockdown, surgery  couldn’t not be done  and she was sent back. Within 1 month all her symptoms subsided and she was alright. 

4 days ago she developed fever, headache, burning micturition, and decreased urine output. She also had 5-6 episodes of vomitings.

PAST ILLNESS:

H/o hysterectomy 15 years ago

Not k/c/o DM 

Not k/c/o HTN

PERSONAL HISTORY:

Diet mixed 

No h/o alcohol consumption 

No h/o smoking 

Appetite: decreased since 1 year

Sleep: inadequate since 1 year 

FAMILY HISTORY:

No significant family history 

EXAMINATION :

General examination:

Patient is conscious coherent and co operative

Patient is moderately build and nourished

No pallor

No cyanosis

No clubbing 

No lymphadenopathy 

No icterus

No oedema

Vitals

BP 110/80mmhg

PR 74 bpm

Temperature 99 F

Respiratory rate 18 per min

SYSTEMIC 

CVS

no thrills

S1 s2 heard

No murmers

RESPIRATORY 

Position of trachea central

No dyspnoea

No wheeze

Breath sounds - vesicular

ABDOMEN 

Obese 

Tenderness present, diffuse

No palpable mass

No free fluid

Liver and spleen non palpable

CNS

Power in both lower limbs 2/5

Reflexes 

Knee -ve

Ankle -ve

INVESTIGATIONS 












PROVISIONAL DIAGNOSIS 

Paraperesis secondary to L4L5 lumbar canal stenosis


TREATMENT 

Inj Methyl prednisolone 1gm/IV/OD

Inj optineuron 2g / IV/ BD

IVF NS  RL @100ml/hr

Inj pan 40mg IV/OD

INJ ZOFER 4mg / IV/Sos










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