70 Y/O male with fever and lower limb weakness

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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input

 This E-blog also reflects my patient's centred online learning portfolio.  

A 70 year old male farmer by occupation came to the hospital with complaints of fever and weakness in lower limbs. 

CHEIF COMPLAINTS: Fever since 10 days generalised body pains weakness in lower limbs since 7 days 

HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 10 days back,then he developed fever

Fever-high grade on and off 

no diurnal variation 

associated with chills and rigors 

intermittent type(alternate day)

relieved after taking medication(paracetamol) not associated with cold, cough, loose stools, vomitings, burning micturation,rash

Patient was taken to local medical practitioner and was diagnosed with?typhoid and ?dengue(dec platelet-52k ,84k) and was treated with antibiotics and other symptomatic medications

Generalised weakness and body pains since 7 days lower limbs pain and weakness , 

pain -dragging type radiating from lower back to thighs (patient had h/o fall from bullockcart and had injury for which was taken to pvt hospital and was told no fractures or abnormalities)

 lower limb weakness - paresis,

 insidious in onset from 7 days,

simultaneous involvement of both limbs,

static (non progressive) 

proximal muscle weakness

 no neck trunk or upperlimb involvement,

no diurnal variation, flaccid 

SPINOMOTOR SYSTEM: pain + at b/l ll tremors + 

SENSORY: no deficits 

HMF: Conscious no speech difficulties memory and sleep disturbances 

CRANIAL NERVES:

 I –no alteration in smell

 II –no blurring of vision/diminished vision, differentiate colours, night blindness

 III, IV, VI –no drooping of eyelids/ double vision/ able to move eyes in all directions

 V – having sensation over the face, able to chew food 

VII – able to close the eyes and lips, deviation of angle of mouth, drooling of saliva, able to feel taste of objects 

VIII – no hard of hearing, tinnitus, vertigo

 IX, X – no difficulty in speech, nasal twang to speech, regurgitation of feeds, difficulty in swallowing 

XI –able to move the neck in all directions, lift the shoulder 

XII – able to roll the tongue and push the food backwards 

ANS: 

Bladder normal 

bowel normal 

no giddiness while waking up 

no sweaating, palpitaions

RELEVANT NEGATIVE HISTORY: 

no h/o lifting heavy objects on the head/back/ spinal anaesthesia

 no vomiting, diarrhoea 

 no calf tenderness no chest pain

 no drug intake – antihypertensives,anticoagulants

 no bed sores, dark coloured urine

 PAST HISTORY: no h/o Similar illness in the past 

no h/o TIA/RIND

 N/k/c/o Diabetes, Hypertension, coronary artery disease, thyroidal illness, Tuberculosis, HIV, malignancy 

no h/ovaccination for dog bite 

no h/o Previous medical illness/surgeries normal Developmental history 

PERSONAL HISTORY: ROUTINE- 

Married 

non-veg (mixed) 

Sleep adequate (now slightly dec)

 Smoking Bedi 1 pack stopped 1.5 year back (30 years) 

Alcohol toddy 1 bottle stopped 2 months back no h/o Drug abuse

 GENERAL EXAMINATION: 

Patient is conscious 

Oriented 

Comfortable 

Co-operative

 Moderately Built 

moderately nourishment 

Afebrile 

No Pallor 

NoIcterus 

NoCyanosis – central/peripheral

 No Clubbing No Pedal edema 

No regional lymphadenopathy 

No Significant lymphadenopathy

 left handed individual 

no neurocutaneous marers seen 

VITALS: 

pulse:87 bpm,normal rythm ,volume ,character ,no radiofemoral delay, 

BP:130/90 mm of Hg 

RR: 20 cpm Abdominothoracic 

temp-98.6F 

NERVOUS SYSTEM EXAMINATION 

1. HIGHER MENTAL FUNCTIONS: 

a. Conscious

 b. Oriented to time, place and person

 c. Speech and language –no aphasia, dysarthria, dysphonia 

d. Memory – immediate-retention and recall, recent and remote -intact 

e. Delusions, hallucinations absent 

f. Emotional lability absent 

g. MMSE score -

I. Orientation 1. date, day, month, season, year 5 

2. floor, hospital. District, state, country 5

II. Registration Name three objects taking one second for each object. Ask him to repeat the same. Repeat till he remembers 3 

III. Attention and Calculation Serial 7’s 5 times 4

IV. Recall Recall the three objects 3 

V. Language 

1. Name 2 objects 2 

2. Repeat a sentence 1 

3. Follow a 3 stage command 3 

4. Reading “close your eyes” 

5. Writing a sentence 

6. Copy a design

CRANIAL NERVE EXAMINATION:

       

1- sense of smell.   +   

2-

i) Visual acuity – Rosenbaum Chart  Normal 

ii) Field of vision – Confrontation test Normal

iii) Colour vision – Ishihara chart.  Normal

iv) Fundus  Normal

3,4,6-

i) Extra-ocular movements present 

ii) Pupil – Size  normal

iii) Direct Light Reflex.  present

iv) Consensual Light Reflex. Present

v) Accommodation Reflex. Present

vi) Ptosis.  absent

vii) Nystagmus.  Absent

5- 

Sensory over face present 

Motor ( mastication ) normal

Corneal ,conjunctival , jaw jerk present

7-

Motor

nasolabial fold-  present 

hyeracusis -absent

occipitofrontalis- normal

orbicularis oculi -normal

orbicularis oris -normal

buccinator -normal

platysma- normal

Sensory 

intact (ant 2/3rd tongue and over tragus sensations)

Corneal conjunctival reflexes present 

Secretomotor normal (buccal mucosa)

8-

Rinnes 

Weber

9,10-

Nystagmus absent 

Uvula , palatal arches , movements - central 

11 sternocleidomastoid normal

12 no tongue deviation or fasciculations

MOTOR EXAMINATION:

Bulk. 

Inspection-normal 

Palpation- normal

Tone-

UL - b/l Hypertonic

LL- Hypotonia

Power 

UL - 

Flexion      5/5.        5/5

Extension 5/5.         5/5

Abduction5/5.          5/5

External rotation5/5.  5/5

Dorsal flexion 5/5.    5/5

Palmar flexion 5/5.   5/5

Hand grip.     Good b/l

LL

Hip            3/5.      3/5

Knee 

Flexion.     4/5.     4/5

Extension 4/5.       4/5

Ankle

Dorsiflexion.  4/5.  4/5

Plantar flexion 4/5.  4/5

REFLEXES: 

              Rt.            Lt

Jawjerk.   ++         ++

Biceps.    +++       +++

Triceps.   +++       +++

Supinator ++         ++

Knee jerk.  +           +

Ankle.      ++            ++

Babinsky absent.    Extensor

GAIT 

pt able to walk  with support

Involuntary movements:

Tremors + upperlimb , fine  tremors 

Sensory system:

Spinothalamic 

Pain. 

UL  Normal b/l

LL.  Normal b/l

Touch equal b/l all limbs

Temperature felt all 4 limbs equally

Dorsal column

Fine touch  present

Proprioception

Ul normal

      Rt.       Lt

Ll  8/10.   6/10

Cortical

2 point discrimination  present b/l

Tactile localisation normal

Steregnosis  present

CEREBELLAR SIGNS:

1. Titubation- absent

2. Truncal ataxia/gait ataxia/ stance ataxia-swaying left

3. Nystagmus -absent

4. Dysarthria -absent 

5. Hypotonia -present 

6. Rebound phenomenon absent

7. Intention tremor- present

8. Pendular knee jerk absent

9. Tandem Walking couldn't be elicited

10. Coordination

a. Upper Limbs – Finger Nose test absent

b. Lower Limbs – Heel Knee test absent

c. Dysdiadokokinesia  present (lt)

ANS: 

No postural hypotension,

resting tachycardia , 

sweating

Meningeal signs 

Neck pain+

No spinal and cranium deformities 

No carotid bruit

Other systems:

CARDIOVASCULAR SYSTEM:

JVP, Apex normally placed, no Palpable P2, Heart sounds – normal, No thrills/murmurs

RESPIRATORY SYSTEM:

Chest symmetrical, No paradoxical movements, Normal vesicular breath sounds heard,

No abnormal/added sound

ABDOMEN:

Abdomen is soft, No organomegaly, No ascites

PROVISIONAL:

Fever with thrombocytopenia with lower limb weakness 

?PCA stroke 

INVESTIGATIONS:

6/9/22:

S

Fever with generalised body weakness and bilateral lower limb pains 

O-

-Fever spikes seen

-Generalised body weakness and bilateral lower limb pains

- neck pain since yesterday night

VITALS

BP- 120/80mm Hg

PR- 85bpm

RR- 20 cpm

Temp - afebrile

SYSTEMIC EXAMINATION

CVS- S1 S2 heard

RS- BAE present

PA - SOFT NON TENDER

CNS

▪sensory examination,- touch, pain present

▪ No muscle wasting seen

▪TONE-         RT.                         LT

 

UL.           hypertonia                hypertonia

LL.             nrml.                         nrml

▪ POWER.

                         RT.                       LT

•UL  

                                            

 Biceps.            5/5.                   5/5

 Triceps.          5/5.                   5/5

 Opponens pollices

                          5/5                   5/5  

 • LL

Extensors of knee

                       5/5.                     4/5  

  Flexors of knee

                     5/5.                       4/5

Exetnsors of hip

                      5/5.                      5/5

External hallucis longus 

                     5/5.                        5/5

 ▪REFLEXES 

 • Deep tendon reflexes

                                   RT.                      LT     

  Knee jerk.          2+                              0              

  Ankle reflex       2+                         0

                               

  Biceps.               3+                            3+

                                       

  Triceps.             2+                           2+

                                   

   Supinator.          3+                          3+

                                    

• Superficial reflexes

▪Babinskis sign 

Flexor on right side

Extensor on left side

 

•Cranial nerve examination

   normal

• Finger-nose in- coordination- yes

•Knee heal test - unable to perform

A-

Vital pyrexia with ? cerebellar stroke

P-

1)IVF 1 NS, 1 RL , 1DNS@ 75 ml/ hr

2) INJ CEFTRIAXONE 1gm IV BD

3)INJ NEOMOL 1gm IV / SOS( if temp >101°F)

4) INJ ZOFER 4mg sos

5) TAB PCM 650 mg PO TID

6) TAB PAN 40 mg IV SOS

7) INJ OPTINEURON 1amp in 100 ml NS IV OD

8) TAB MVT PO OD

9) TAB HIFENAC PO/ BD

10) TAB NEUROKIND LC HS

11)TEMP MONITORING 2nd hrly

12) BP, PR monitoring 4th hrly 

13) GRBS monitoring 6th hrly