48 year female born and bought up in thopicherla to a family of 6 members including four siblings , mother and father. achieved normal milestones. Childhood was pleasant. Father used to do pottery. When I asked how much is the income of her father and that people only buy mud pots only during summer, how would family earn money in other seasons- patient answered that summer is a great business deal for us, but there are many other occasions like temple room,weddings, funerals etc where people use mud pots .
Her teacher is a male and alcoholic who used to beat kids, in fear of that she stopped going to school.
At age 9 patient had pain abdomen which was diagnosed as appendicitis and underwent appendectomy
She lost her father 15 years ago due to old age. Mother is now older than 100 years bedridden stays at her elder sister home
Later she lost her elder brother due to cancer at Osmania General hospital
At age 18 patient attained menarche, in the same year she was married and moved to miryalgauda and started working as a maid in houses. She had one girl child after marriage. 10 years ago she lost her husband due to heavy alcohol consumption. Since then she raised the kid all by herself. When her kids age was 9 she was unable to grasp and learn languages like English and Hindi for which her teachers used to beat her up. Seeing the scars she felt low and discontinued the studies and married her off to an auto driver who later had two children(girls)
10 years ago she had giddiness, went to local hospital and was diagnosed with hypertension
6 years ago her daughter gave birth to a girl child, while she was taking care of the child she had sudden onset of giddiness and had a fall, got hurt on her head by knocking onto foot of bed, as she was bleeding her daughter called out for neighbors for help, one woman came and applied tea powder to stop the bleeding. Later she was taken to hospital and had four sutures at the site. One week later as patient wound healing was delayed she went for a follow up and diagnosed with Diabetes. She was advised to cut her hair for fast wound healing, as hairs can cause sweat and therefore delay the healing. Since then she had complains of neck pain
4 years ago while patient was talking to a lady on road, she suddenly pushed her onto the road which made her land up in hospital with fracture to her right lower limb. She had fast recovery and used support of a walker for a while and later walked normally on her own.
One year ago in March 2023 patient had sudden onset of deviation of mouth, went to hospital, CT head was done and counselled that patient had blood clot in the brain. Was admitted for 10 days in neuro hospital, during the stay her BP was 200 and sugars were 600. All her parameters were corrected and patient was discharged
6 months after the discharge patient had sudden onset of tremors in left hand followed by left hand weakness, one week later she had weakness of left lower limb, one week later she experienced similar complains in right upper and lower limbs.
DIET- MIXED
BOWEL AND BLADDER- REGULAR
ADDICTIONS- occasional toddy drinker
DAILY ROUTINE
BEFORE ILLNESS
wakes up at 6am, freshen up , cleans home and used to go for work by 7am
Works in three houses till 12pm -cleans and sweeps floor, wash utensils, lunch provided and come back to her home by 12pm
Returns home, wash clothes, dry them and Have lunch and takes nap till 4pm
At 5pm she again go for work and returns home by 7pm
At 9pm she goes to bed - no sleep disturbances
AFTER ILLNESS
All her routine was changed, and had to depend on someone even to go for washroom which made her more anxious. She often has insomnia and spends time mostly on bed.
VITALS
TEMP-97.8F
PR- 80bpm
RR- 23cpm
BP-130/80mmhg
SPO2-98% at RA
GRBS- 123mg/dl
EXAMINATION
CNS
TONE - NORMAL IN ALL FOUR LIMBS
POWER- RIGHT LEFT
UL 4/5 4/5
LL 3/5 3/5
UPPER LIMB REFLEXES - NORMAL
LOWERLIMB DEEP TENDON REFLEXES - EXAGGERATED
SENSORY- INTACT
CVS-S1S2 NO MUMRMUR
RS- BAE NVBS
PA - SOFT NT
PROVISIONAL DIAGNOSIS
MOTOR NEURON DISEASE
Known case of HTN DM CVA
Abdominal circumference - 104cms
Waist circumference- 98cms
Hip circumference -108cms
Mid arm circumference- 26cms
Body weight- 65kgs
INVESTIGATIONS
ECG
PaJR
[11/06/24, 19:25:12] Chandana Mam Gen Med: In the context of this patient with quadriparesis, I remembered an interesting similar case that I experienced. I saw a 60-year-old male who, over the last 2 years, initially had weakness in his left lower limb, followed by his right lower limb, then his left upper and left lower limbs (although not classically Elsberg phenomenon) involving both distal and proximal muscles by the time he presented (distal muscles followed by proximal in all limbs) . We thought it could be Elsberg syndrome, as he also complained of severe neck pain and low back pain for the last 3 months.
He gave a occasional history of fasciculations (kanda adurutundi) only in the first dorsal interspace of both hands. He also complained of occasional tingling sensations in both palms. We considered MND (motor neuron disease) to be unlikely due to the sensory complaints and going by textbooks, which say that MND causes more wasting compared to weakness.
However, on examination, we could not find any sensory abnormalities. Only his first dorsal interspace was wasted, and his EDB (extensor digitorum brevis) was wasted upon toe extension examination on both sides. There were no tongue fasciculations or other visible fasciculations. All deep tendon reflexes (DTRs) were exaggerated with spastic quadriparesis and upgoing plantar responses. An MRI of the spine was reported as multiple osteophytes and spondylotic changes in the cervical spine region. This initially led us(PGs) to consider cervical spondylosis as a cause for his quadriparesis.
However, upon further review of the films with faculty, we realized that despite the osteophytes and spondylotic changes, there was no spinal compression. He was diagnosed with MND. I learned that cervical spondylosis with myelopathy is the primary differential diagnosis for MND in such presentations which I dint knew before.
The uncertainty was in the complaints of occasional tingling sensations and his neck pain was attributed to spondylotic changes in cervical spine.
[11/06/24, 19:30:42] Rakesh Biswas Sir: Yes Elsberg's classic description of the U need not fit to a tee and it's probably just the sequential progression in the limbs that's characteristic of cervical myelopathy that as you pointed out can be non compressive too but if when proven to be compressive it can also be labelled secondary MND
[11/06/24, 19:31:52] Rakesh Biswas Sir: Any radiology opinion on this?
[11/06/24, 19:32:38] Rakesh Biswas Sir: Can someone share her complete neurology examination findings?
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