Prepared By-Prepared By-Dr. Md Nazrul Dr. Md Nazrul IslamIslamMBBS, M . sc. (B MBBS, M . sc. (B M E).M E).

HISTORY :

Appearance : Ill looking Body built : Average. Patient is concious, co-operative

and well orientated. Decubitus: Sitting & Lying Anaemia : Absent Jaundice : Absent Cyanosis ; Absent Odema : Absent. Pulse : 85 b/m. Blood pressure : 130/70 mm Hg.

Respiratory rate : 16 per min.Respiratory rate : 16 per min. Temp : Normal.Temp : Normal. Koilonychia : Absent.Koilonychia : Absent. Leukonychia : AbsentLeukonychia : Absent Neck gland : Not palpable.Neck gland : Not palpable. Lymph node : Not palpable.Lymph node : Not palpable. J.V.P : Not raised .J.V.P : Not raised . Thyroid gland : Not palpable.Thyroid gland : Not palpable. Skin pigmentation : Absent.Skin pigmentation : Absent.

Inspection : Inspection : There is no swelling or deformity .There is no swelling or deformity .Palpation : Palpation : Tenderness present over cervicalTenderness present over cervical spine.spine. Local temperature normal.Local temperature normal. There is no enlarged lymph node &There is no enlarged lymph node & thyroid gland.thyroid gland.Movement : Movement : (movement of the Cervical Spine )(movement of the Cervical Spine ) Flexion – painful & restricted Flexion – painful & restricted Extension – painful & restricted Extension – painful & restricted Lat flexion – painful & restricted Lat flexion – painful & restricted Rotation – painful & restrictedRotation – painful & restricted..

EXAMINATION OF THE NECK:

Gait : Patient cannot walk & stand. Inspection : There is a swelling & deformity in the anteromedal aspect of the left leg. Muscle wasting present in the lower limbs.Feel : Localized temperature slightly raised in the

middle part of left leg. There is tenderness miled deep tenderness present in the left middle part of the left leg. All pheripheral pulses are normal.

Measurement : Left lower limb is shorten by I & ½ cm.

(Tibil component) Movement : All joint movement of both

upper and lower limb Active movement – weak. Passive movement – Normal Patient cannot walk on left leg.

LOCOMOTOR SYSTEM :

LOOKLOOK Swelling and deformity over the middle part of the left leg. Tenderness present. Abnormal mobility in deformed

area. Skin condition over the deformed

area is normal. No discharging sinus. No vascular deficiency.FEELFEELTenderness present.Temperature slightly raised.Peripheral pulses intact.

Left knee – joint movement can not be elicited due to painful condition.Ankle joint- Planter flexion --- weak in

active & normal in passive movement. Dorsi flexion --- weak in active & normal in passive movement. Hip Joint- Extension and Flexion Normal in passive week in active

movement. Adduction --- normal Adduction --- normal

MOVEMENT

Examination of the left lower limb:

Higher psychic function --- normalHigher psychic function --- normalAll cranial function --- normalAll cranial function --- normalMotor functionMotor functionGeneralized muscles wasting of both Generalized muscles wasting of both

upper upper and lower limbs.and lower limbs.Palpation – Bulk of muscle – Palpation – Bulk of muscle –

wastedwasted tone of the muscle – tone of the muscle – IncreasedIncreased

Perianal Sensation – Perianal Sensation – normalnormal

Anal tone – Anal tone – present.present.

Cremasteric reflex – Cremasteric reflex – presentpresent.

Systemic Examination :

Regarding muscle power

Upper limb – Shoulder (left &Rt) – Flexion – 4Extention – 5 Abduction - 5 Adduction - 5 ELBOW (left &Rt) – Flexion -5Extention -4WRIST (left & Rt.) – Flexion – 4Extention – 4Hand (left &Rt) Grip -Weak 4Finger adduction & Abduction- 4

Systemic Examination :

Sensory function of upper limbs– Deminished.Jerks of upper limbs Biceps Jerks - exaggerated Tricep Jerks - Exaggerated

Brachioradialis Jerks - exagerated

Hoffmann’s sign test - Positive.

Jerks of Lower Limbs –Knee Jerk - Exaggerated Ankle Jerk - Exgcerated Babushkas Sign - Positive.

Sensory and Motor:Sensory and Motor:

Systemic Examination :

Muscle power – (Rt & Lt- Lower limb) Hip – Flexion - 5 Extention – 5 Abduction – 5 Adduction – 5Knee (Rt) - Flexion – 5 (Muscle power of the

left knee can not be elected due to

deformity. & swelling of left leg) Extention - 5 Ankle (Rt & Lt) - Planter Flexion – 5 Dorsiflexion – 5Toe extensor and toe flexor (Rt. & Lt.) - 4+Sensory funtionof lower limbs-

diminished.

Systemic Examination :

Inspection – No abnormality detected Palpation – not tnederAuscultation – Bowel sound presentP/R – Anal tone – present.

Inspection – Normal in size and shape of the cheast.

Resp. rate – 16/mint.Palpation – Tachea – Centrally placed Normal cheast expansibility.Percussion – ResonanceAuscultation – Bronchial breath sound

with no added souund.

Alimentary System

Respiratory System

Systemic Examination :

Pulse – 84/mint.B.P – 120/70 m. m of HgJ.V.P – Not raisedInspection – N.A.DPalpation – Apex beat at the 5th intercostal

space.Percussion – Superficial cardiac dullness

present over precordiuam Auscultantion- S1 and S2 audible.

The patient unable to pass urine normally and the patient is in Cathder.

Cardio-Vascular System

Genito – urinary systim

Systemic Examination :

Md. Kanu, Aged – 40yrs. Coming from Md. Kanu, Aged – 40yrs. Coming from adaber–10, Mohammadpur, Dhaka, admitted adaber–10, Mohammadpur, Dhaka, admitted on 08.08.11 in S.S.M.C.Hon 08.08.11 in S.S.M.C.H

with the complains of -with the complains of - Weakness of the both Upper and lower limb Weakness of the both Upper and lower limb

and enability to move.and enability to move. Difficulty inn passes of urine and stool.Difficulty inn passes of urine and stool. Fracture of the left leg following RTA – 2 Fracture of the left leg following RTA – 2

weeks back.weeks back. At this stage he was unable to stand and At this stage he was unable to stand and

walk. His upper limbs were so weak that he walk. His upper limbs were so weak that he can not grip anything. can not grip anything.

He is on Catheter as he could not pass He is on Catheter as he could not pass urine. His Facial injury at the chin was healed urine. His Facial injury at the chin was healed up. There is a swelling and deformity at the up. There is a swelling and deformity at the middle of lower leg which is immobilized with middle of lower leg which is immobilized with bamboo – sticks by kobiraj. bamboo – sticks by kobiraj.

Salient Features:Salient Features:

He had a RTA 2 months back and with fracture of the left leg bones which was Maltreated by Kabiraz.

He had no history of loss of conciounoss, weight loss, anorexia & fever.

On General examination the patient is ill looking non-diabatic, non-icteric normotensive, conscious, co-operative and well orientated.

On Local Examination- Face: Scar mark over the left side of race

near chin. Neck movement – Restricted and painful.

Salient Features:Salient Features:

Active movement of the joint of the limbs are weak.

There is Generalized muscle wasting and weakness of the Limbs. Sensory and Motor function of the limbs–Dimished. (M.R.C grade– 2).

All Jerks are (The Jerks of the upper and lower limb)

exaggerated Tone of the muscle – Increased Perianal sensation – Intact Anal tone – Intact.

Salient FeaturesSalient Features::

Patient is on catheter. There is an diffuse swelling over the

middle third of the left leg which is tender and abnormal mobility present.

Peripheral Vascular status – Normal. Other systemic examination reveal

no abnormality (Except Nervous, urinary

& loco-motor system).

Salient FeaturesSalient Features::

Provisional Provisional Diagnosis- Diagnosis- ????

Incomplete Cervical Incomplete Cervical Spinal injury (At C4/C5) Spinal injury (At C4/C5) ((Central cord Central cord Syndrome) Syndrome) with fracture Left tibia with fracture Left tibia & fibula& fibula.

Provisional Diagnosis-

• Anterior cord syndromeAnterior cord syndrome• Brown – Sequard SyndromeBrown – Sequard Syndrome..

Differential Differential Diagnosis Diagnosis --

Blood – C.B.C (3.7.11)Hb – 10.5gm% E.S.R – 25mm in fast hourN – 64%L – 30%M – 02%E – 04%R.B.S – 6.8 mmol/L (28.7.11)Blood urea – 34mg/dlBlood Creatinine – 0.90mg/dlS. Electrolytes – (28.7.11)Na – 135mmol/LK – 3.8 mmol/LCl – 100 mmol/L

E.C.G – within normal limit

Investigations:

X-ray cheast – N.A.D X-ray Cervical Spine – Lose of lordosis C4/C5 – post. Listhesis (Grade -1) Degenerative change – in all Cervical Spine

X-ray left leg – Comminuted fracture of the middle of the shaft of the left

tibia and oblique fracture of the

proximal fibula.

Investigations:

MRI-

Degenerative disc & spine disease. Focal myelitis at C4 – C5 – level. C2 – C3, C3 – C4, c5 – C6, C6 – C7: Disc bulging with corresponding thecal sac indentation. C4 – C5: Central and both para-central disc protrusion with corresponding spinal canal stenosis & foraminal narrowing.

M.R.I Cervical Spine -

Investigations:

.

Incomplete Cervical Spine injury at C4 –C5 level,with Quadriparesis (Central cord

syndrome) and Closed comminuted fracture of left tibia and fibula.

Confirmatory diagnosis-

For Spinal( Cervical) injury -For Spinal( Cervical) injury - conservative by Semi-rigid

Cervical Collar. For retention – Catheterization

and bladder exercise. physiotherapy (Active and passive

exercise of the limbs) For Fracture tibia fibula – Close reduction and plaster

immobilization in the form of long leg full plaster.

34

– After 2 month.Gait – Patient can stand and walk with support.Muscle power (MRC Scale) – 4Active movement of the4 joints of the limb – Almost Normal.Griping power of the hand increased so that he can eat himself.Bulk of the muscale – improvedJerks are still – exagratedClonus – Absent For fracture tibia –fracture is uniting.But the patient is still unable to pass urine without catheter, but can pass stool voluntarily.

Final follow up Final follow up

Incepta Incepta Pharmaceutical, Pharmaceutical, Dhaka, Dhaka, BangladeshBangladesh..