CASE ON TRANVERSE MYELITIS

36 Tejaswi enduri 





GENERAL MEDICINE
    
Hello all. This is Tejaswi, a third-semester medical student. This e log depicts the patient-centered approach to learning. 

This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Note: This is an ongoing case and will be updated as and when we find new information. 

         This e log is made under the guidance of Dr.Nikitha




CASE SHEET 

Date of admission:17/7/21


CHIEF COMPLAINT :

a 40 yr woman presented with 

pain on passive movements of the hip, 

burning sensation of epigastrium 

difficulty in moving both the legs from -  last night 

sensations absent from the umbilicus down from - last night 


HISTORY OF PRESENT ILLNESS:


the patient was apparently asymptomatic 3 days back 

later  developed generalized body aches and lethargy,  was treated by a local RMP with tablets and injections, 

which reduced the pain but followed by increased weakness 

5 pm yesterday - 
                              the patient was taken to an outside hospital 

where developed a sudden onset of loss of  power in both the lower limbs 

and wasn't able to walk 

she wasn't able to sense clothes perceive pain, cold, hot.

she was unable to move side to side due to pain 

pain on passively moving the legs sideways 

the patient was able to perceive the sensation of bladder fullness and  was able to pass urine and stools 
 
last night - 

was put on Foleys 

she did not pass stools 

developed nausea ,vomiting neck pains ,fever,photo/phonophobia, 
 
The patient is able to comb  and hold objects and sense clothes above the umbilicus 

the patient is able to lift the neck above and swallow 

HISTORY OF PAST ILLNESS:

• Not a k/c/o
            DM, HTN, CAD, asthma, TB, epilepsy 

no similar complaints in the past 

no H/O trauma, fall before the episode

no giddiness 

PERSONAL HISTORY 

• She is married, and a housewife

• Her appetite is normal, Nausea present . Follows mixed diet. 

• Her bowel habits and micturition is normal. 

• Has no known allergies and no addictions. 

TREATMENT HISTORY 

no specific treatment history 

FAMILY HISTORY :

• Has no family history of DM, HTN, TB, asthma, CAD, strokes, cancers, heart diseases, .

PHYSICAL EXAMINATION:
  •  Pallor - absent 
  •  icterus - absent
  •  cyanosis - absent
  •  clubbing of fingers/toes - absent
  •  dehydration - mild
  •  lymphadenopathy

VITALS : 

  •  temperature - afebrile 
  •  pulse rate - 70/min
  •  Bp- 100/60 
  •  SPO2 - 97%
  • GRBS- 97mg%


SYSTEMIC EXAMINATION :

CENTRAL NERVOUS SYSTEM:

• Pt, conscious, coherent, and cooperative
• Speech is normal
• no signs of meningeal irritation

SENSORY

UL -  + B/L                               R           L
LL-    fine touch                        +           +
         pain                                 +           +
         temperature 
         proprioception                 +          +
         joint position                    +          +
         vibration


MOTOR                     
                   UL 
tone            R             L
                   N             N
                              
                    LL 
                    R             L
                    ^              ^sed

POWER     -UL                Rtt              Lt            LL         Rt              Lt 

             proximal            4+/5            4+/5                       3+/5           3+/5
             Distal                 4+/5            4+/5                       3+/5          3+/5 
             Handgrip            80%            80%


CARDIOVASCULAR SYSTEM:

• S1, S2 +

RESPIRATORY SYSTEM:

BAE + NVBS

 ABDOMINAL EXAMINATION:

scaphoid shape 
no tenderness 
no palpable mass
no free fluids 
liver and spleen nor palpable

PROVISIONAL DIAGNOSIS : 

         
 TRANSVERSE MYELITIS 


INVESTIGATIONS :


HAEMOGRAM 

Hb- 12gm/dl

total count - 4,300 cells /mm

smear - normocytic normochromic impression 


Serum electrolytes 
 
Na + = 131 mEq/l 

K+ =  3.8 mEq/l

chloride =98-100mEq/l
 
serum ca +2 = 9.8 mg/l 

serum creatinine = 0.9 mg/dl

RBCS - 73 mg /dl 

Blood urea - 34 mg /dl 



 
MRI



















CROSS CONSULATION WITH ORTHO 








TREATMENT 

Inj - PANTOP 40mg 
Inj -  ZOFER  4 mg
Inj - TRAMADOL 1 amp in 100 ml 
Inj -  OPTINEURON 1amp  in100ml 
Tab -  MYORIL 4mg 
 
 

DAY 2 ( 18/7/21)


C/o -nausea 
pain in B/L LL 

Pt c/c/c 
PR = 66
BP = 100 /60 
CVS = S1S2 +
RS = BAE +
P/A = SOFT ,NT
CNS= NFND 
  
POWER = B/L LL = 3/5 
                           UL= 4/5 

Hyperreflexia =B/L LL 
              N      = UL 

TONE = ^ m B/L LL 
              N m UL

TREATMENT 

Tab -  PAN - D 40 MG 
Tab -  PREGABA- NT 75 / 10 mg 
Tab  - MYORIL 4 mg 
Tab -   PREGABA- NT 75 / 10 mg 
Inj -  TRAMADOL 1 amp 100ml
Inj -   OPTINEURON 1 amp in 100ml 
Inj-   ZOFER 4 mg iv 

DAY 3(19/7/21)


C/o. Pain in B/L   LL
Nausea  
Stools still not passed 

PR = 80 bpm
Bp = 90/60 mm of Hg
Cvs= S1 S2+
Rs= BAE+ , NVBS
P/A= soft 
CNS = NFND

TREATMENT 

 Tab -  PAN -D 40 mg 
Tab -  ULTRACET 
Tab -  MYORIL 4 mg 
Tab-  PREGABA-NT 75/10 mg
Inj -  TRAMADOL 1 amp in 100ml 
Inj-  OPTINEURON I amp in 100ml 
Inj - ZOFER 4m

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