grand round 1

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Title: grand round 1

1
GROUND ROUND PRESENTATION

PRESENTERSLIGHTNESS KIMAMBO,DAVID KIZENGA,
IRENE KIMARO,NAILA KHIMJI,ASHNA KHALIL,
FACILITATORS DR JOYCE SABUKA DR WENSESLAUS MARO

2
PATIENT PARTICULARS

NAME F.J.C
SEX FEMALE
AGE 23 YEARS
ADDRESS MBEZI BEACH
TRIBE LUGURU
OCCUPATION STUDENT
RELIGION CHRISTIAN
MARITAL STATUS SINGLE
EDUCATION LEVEL O-LEVEL
INFORMANT PATIENT
NEXT OF KIN MOTHER
DATE OF ADMISSION 01/01/2024
DATE OF CLERKSHIP 02/01/2024
NUMBER OF HOSPITAL STAY 1 DAY
REFFERAL SELF REFERRAL

3
CHIEF COMPLAINT

Lower Limb Weakness for 7 days

4
HISTORY OF PRESENTING ILLNESS

The patient present with gradual onset of
lower limb weakness for 7 day which was
progressing.
1 day prior to onset of symptoms she reported
to have long walk and climbing mountain at
Morogoro.
Initially she could walk with support and
on the next day she was unable to walk even with
support.
She could use her upper limbs normally and
no noticeable changes reported.
It was associated with numbness and tingling
sensation
with inability to control urine and stool.
She reports no blood in stool and urine, no flank
pain, no diarrhea

5
CONT

She massaged herself with warm water,
which made her sustain blisters and wounds at
lower limbs.
However the patient denied h/o
headache, dizziness, blurry vision, convulsions,
tremors, muscle pain, joint pain / swelling, loss
of consciousness,
No h/o
recent Trauma/ lifting heavy object
Open Tb contact , drenching night sweats,
significant weight loss

6
REVIEW OF OTHER SYSTEMS

EENT (EARS, EYES, NOSE AND THROAT)
No history of ear pain , discharge or hearing
loss
No history of eye pain, discharge or loss of eye
sight
No history of nasal pain, discharge or bleeding,
no loss of smell
No history of throat pain or painful swallowing
CARDIOVASCULAR SYSTEM
No hx of central chest pain
No hx of difficulty in breathing on lying flat
No hx of awareness of heartbeats
No hx of lower limb swelling

7
CONT

RESPIRATORY SYSTEM
No hx of chest pain
No hx of difficulty in breathing
No hx of cough
No coughing up blood
No hx of wheezing

8
CONT

ENDOCRINE SYSTEM
No excessive thirst
No heat intolerance
No cold intolerance
No excessive urination
INTEGUMENTARY SYSTEM
No itchy skin
No skin discoloration
No skin lesion.

9
PAST MEDICAL HISTORY.

This is her first admission.
Patient has had previous two OPD visits in a
dispensary in Kawe for back pain.
The first visit was in September 2023 and she was
diagnosed with UTI and treated by medication.
The second visit was in December where she was
given tramadol to relieve the pain.
She has no history of any other chronic illness
like HTN, DM, SCD.
She has no history of surgery and blood
transfusion.
Patient has no history of long-term medication
No hx of food/drug allergy.
No hx of using herbal medication

10
GYNECOLOGICAL HISTORY

Attained menarche at 16years
Has regular cycle of 30 days and her periods last
for 3 to 4 days
She uses approximately three pads per day which
are not fully soaked with blood.
No severe pain during menstruation
Last normal menstrual period was on 23rd December
2023
No hx of contraceptive use

11
FAMILY HISTORY

2ND born out of 5 children
All her siblings are well and alive.
Both her parents are well and alive
No history of familial illness (DM, HTN, SICKLE
CELL, HAEMOPHILIA) in maternal/paternal side.
No history of sudden death in the family.

12
SOCIAL HISTORY

She is single, has no children and is not
sexually active.
She has no history of alcohol intake
No history of smoking.
She lives in a well ventilated house and sleeps
under a mosquito net.
She does not do physical exercise.

13
DIETARY HISTORY

She takes 3 meals per day,
In the morning she takes Bread and Tea,
In the afternoon she takes Ugali and meat with
vegetables.
At night she takes rice and beans with fruits.
She also takes about 1 litre of water per day.

14
SUMMARY 1

F.J.C, a 23 year old female student who presented
with lower limbs weakness for 7 days which was
progressive in nature associated with numbness
and tingling sensation, dual incontinence.
No hx of headache, convulsion, loss of
consciousness or fever.
Hx of back pain 3 months prior
No hx of trauma, weigh tloss , drenching night
sweats or open tb contact

15
CLINICAL DIAGNOSIS BASED ON HX

Paraplegia secondary to Transverse Myelitis
Point for
Acute onset of Paraplegia,
Age young 23 y/o,
Numbness and tingling sensation,
Urine and fecal incontinence
Differential diagnosis based on history
Potts disease
Point for
progressive in nature, paraplegia, h/o back pain
Point against
no h/o productive cough, night sweats, no fever,
no significant weight loss

16
Cont..

Spine tumors
Point for paraplegia, h/o back pain
Point against acute progression, weight loss,

17
PHYSICAL EXAMINATION

GENERAL EXAMINATION
conscious ,
with a green cannula on her right cubital fossa
for iv medications
urinary catheter with a urine output of 100mls
She had
Evenly distributed black colored hair, which were
not easily pluckable.
Was pale , not jaundiced and not cyanosed
Dry mucous membranes, no sunken eyes
Has normal ears with no discharges.
No nasal blockage, no nasal discharge.
No angular cheilitis, normal dental formula,
no atrophic glossitis and no oral thrush

18
Cont..

No finger clubbing, no koilonychia, no
Leukonychia,
no splinter hemorrhage, Normal capillary refill
of less than 2 seconds,
no palmar erythema, no Oslers nodes, no Janeway
lesions ,
no peripheral lymphadenopathy
Has no lower limb oedema with blisters and
dressed wounds discharging sero sanguinous
VITALS
BP 114/60mmhg
Pr 98b/m
RR 19C/M
TEMP 38.4C
SPO298 IN RA
CONCLUSION PATIENT WAS FEBRILE

19
NERVOUS SYSTEM

Higher center
The patient had good behavior and attitude
towards answering questions.
The patient had good memory could recall
the asked listed objects asked- short term
could name the first president of Tanganyika-long
term
she had normal speech.
The patient was conscious, well alert and
oriented to person, place and time with a Glasgow
Coma scale of 15

20
CRANIAL NERVE EXAMINATION

CN I. OLFACTORY
The patient could smell soap with each nostril
at a time with the eyes closed.
CN II. OPTIC
Visual Acuity The patient was able to see near
and distant objects with both right and left
eyes.
Visual Field The patient was able to see both of
my fingers at the same time while looking at my
eyes with either eye closed.
Pupil size and shape were bilaterally
normal,Pupillary constriction to light It was
positive
CN III, IV VI. OCCULOMOTOR, TROCHLEAR
ABDUCENS Movements of eyes in all direction was
normal
CN V. TRIGEMINAL Motor root The patient could
clench the teeth
Sensory roots the patient responded to light
touch on ophthalmic, maxillary and mandibular
areas

21
CONT

CN VII. FACIAL
The patient could wrinkle the forehead, raise
eyebrows, show teeth, blow both cheeks, and
whistle.
The patient can shut both eyes strongly enough to
resist opening.
Sensory The patient was able to detect sweet,
salt, sour bitter when tested with sugar and
salt.
CN VIII. VESTIBULOCOCHLEAR
The patient could hear the sound from 2 feet away
from both right and left ears.
Balance Could not been done as the patient was
unable to walk.
Rinne's test Air conduction was better than bone
conduction in both right and left ears.
Weber test Was positive.
CN IX. CN X GLOSSOPHARYNGEAL VAGUS
Both sides of the palate move fully and
symmetrically

22
CONT

CN XI ACCESSORY
Could turn her neck sideways against resistance.
The patient could shrug her shoulder against
resistance.
CN XII HYPOGLOSSAL
The patient could protrude his tongue and move it
side to side.
No deviations or tremors were present

23
MOTOR COMPONENT
R. U. L L. UL R. LL L. LL
Bulk NORMAL NORMAL NORMAL NORMAL
Involuntary movement NIL NIL Nil NIL
Gait - - NOT ASSESED NOT ASSESED
Tone NORMAL NORMAL LOW LOW
Power 5/5 5/5 0/5 0/5

24
REFLEXES
DEEP TENDON REFLEX RIGHT SIDE LEFT SIDE

BICEPS NORMAL NORMAL
TRICEPS NORMAL NORMAL
PATELLA REDUCED REDUCED
ACHILLES DECREASED DECREASED
BABINSKI NO RESPONSE NO RESPONSE
25
SENSORY EXAMINATIONLOSS OF SENSATION FROM LEVEL
OF UMBILICUS BILATERALLY.
Rt UL LT UL RT LL LT LL
PRESSURE NORMAL NORMAL NO- NO
VIBRATION NORMAL NORMAL NO NO
FINE TOUCH NORMAL NORMAL NO NO
CRUDE TOUCH NORMAL NORMAL N0 NO
TEMPERATURE NORMAL NORMAL NO NO
PAIN NORMAL NORMAL NO N0
PROPRIOCEPTION NORMAL NORMAL NO NO
26
RESPIRATORY SYSTEM

On inspection Symmetrical chest in morphology.
There was no any therapeutic or surgical scars.
The chest movement was symmetrical with a
respiratory rate of 19 breaths per minute.
There was no use of accessory muscles in
breathing.
On palpation
No palpable supra clavicular and axillary lymph
nodes.
Both breasts was palpable and normal in all
quadrants.
The trachea was placed in the midline and the
cardiac apex beat was felt at the left 5th
intercostal space, anterior axillary line.
There was normal tactile vocal fremitus
Symmetrical chest expansion on both sides of the
lungs.

27
CONT

On percussion
Both the lung fields were resonant on
percussion.
On auscultation
Normal vesicular breath sounds were heard
The vocal resonance was equal on both the sides.

28
CARDIOVASCULAR SYSTEM

The radial pulse was 98 beats/minute,
Regular regular with normal character
synchronous with the contralateral pulses.
Blood pressure of 114/60mmhg at supine lying
position
heard at 1st and 5th Korotkoff phase.
There is no raised jugular venous pressure.
Negative abdominal jugular reflux

29
Cont

On precordial exam
On inspection
No therapeutic or surgical scars, no precordial
bulging or precordial hyperactivity.
On palpation
cardiac apex beat felt at the left 5th
intercostal space, anterior axillary line,
with no heaves no palpable thrills.
On percussion
There was dull note heard over the area of the
heart extended
from left mid axillary to the mid sternal
border.
On auscultation
Normal S1 and S2 were heard.
There was no any added sounds, no other sounds
and no extra sounds were heard.
No any basal crackles were heard at the bases of
the lungs.
No palpable tender liver.

30
GASTRO INTESTINAL SYSTEM

Oral examination
Normal dentition, no angular stomatitis, no
angular chelitis.
Per abdomen.
On inspection
There was normal abdominal contour and
symmetrical move with respiration.
Normally inverted umbilicus.
There was no any surgical or therapeutic scars
on the abdominal.
There was no any distended veins

31
Cont

On palpation
Negative pointing sign.
There was no tenderness or any palpable mass
during superficial and deep palpation.
Spleen, liver, left and right kidneys were not
palpable.
Liver span 12cm
On percussion
There was a tympanic note heard on the abdomen.
No shifting dullness.
On auscultation
3 bowel sounds per minute were heard.
There were no any vascular bruits heard

32
CONT

DIGITAL RECTAL EXAMINATION
INSPECTION Normal anal verge with no fissure,
hemorrhoid, skin erythema and tags seen
PALPATION reduced anal tone ,free smooth anal
mucosa with no nodule/swelling with gloved finger
not stained with feaces and blood
PER VAGINAL EXAMINATION
INSPENCTION No abnormal Per vaginal discharge,
no warts, normal perineum
PALPATION no mass seen, cervix is closed

33
Summary 2

F.J.C, a 23 year old female student who presented
with lower limbs weakness for 7 days ,
progressive in nature A/w numbness and tingling
sensation, dual incontinence.
H/O of back pain 3 months prior
No hx of headache, convulsion, loss of
consciousness or fever
No hx of trauma, weight loss , drenching night
sweats or open tb contact
O/E of Patient was febrile (38.4C),pale with
blisters and dressed wounds discharging sero
sanguonous on both limbs, hypotonic , No muscle
contraction seen 0/5,hyporeflexia,negative
Babinski and loss of sensation from T10.

34
DIAGNOSIS BASED ON HX AND EXAMINATION

1. Paraplegia from T10 secondary to Transverse
Myelitis
Point for Acute onset of Paraplegia, Age young
23 y/o, Numbness and tingling sensation, Urine
and fecal incontinence
with hypotonia , No muscle contraction seen
0/5,hyporeflexia,negative Babinski and loss of
sensation from T10.
Differential diagnosis based on history and
examination
Potts disease
Point for progressive in nature, paraplegia, h/o
back pain
Point against no h/o productive cough, night
sweats, no fever, no significant weight loss

35
Cont..

Autoimmune disorders to r/o multiple sclerosis,
GBS -gullian barren syndrome, SLE
Reason for sudden progressive onset of
paraplegia, young age- 23 years, loss of pain,
pressure and touch sensation., progress in days
to weeks from onset of symptoms, h/o UTI and
back pain 3 months ago.
Reason against patient does not have DIB
Inflammatory disorders- Malignancies- spinal cord
metastasis
Reason forparaplegia, h/o back pain
Reason against acute progression, no weight loss
2. superficial burn injury of the lower limb
grade 1
Reason blisters and wounds following massaging
with warm water, fever

36
MANAGEMENT

Investigation that was supposed to be done
Baseline investigation
FBP
ESR
CRP
LFT
RFT
Pus swab culture and sensitivity
Provided initiative treatment and councelling.
TUMOUR MARKERS
CARCINONO EMBRYONIC ANTIGEN ,CANCER ANTIGEN 125,
ALFA FETO PROTEIN ,HUMAN CHORIONIC GONADOTROPHIN
LACTATE DEHYDROGENASE

37
Investigations to be done

Specific Investigations.
MRI TOTAL SPINE WITH CONTRAST
CSF ANALYSIS

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TREATMENT DONE IN WARD

IV AMOXYCLAV 1.2MG BD FOR 2/7
METRONIDAZOLE INJ 500MG TDS 5/7
IV PARACETAMOL 1GM TDS FOR3/7
TIZANIDINE HYDROCHLORIDE(MUSCLE RELAXANTS) 4MG BD
FOR 3/7
SILVER SULFADIAZINE CREAM 10MG APPLY BD FOR 2/52
To do a wound dressing

47
DISCUSSION

PARAPLEGIA

48
PARAPLEGIA

Paraplegia means paralysis of the legs.
It is caused mainly by disorders of
the spinal cord and the cauda equina.
They are classified as traumatic and non
traumatic.
Traumatic paraplegia occurs mostly as a result of
road traffic accidents and falls
Non traumatic paraplegia (NTP) has multiple
causes
most common cause of adult neurological hospital
admissions in Africa
after stroke and infection

49
NON TRAUMATIC PARAPLEGIA
50

Common causes of paraplegia in Africa
Potts disease (TB)
Inflammation (transverse myelitis)
Malignancy (metastases)
Infection (HIV)
Nutritional (konzo)

51
LOCALIZATION OF THE SPINE

The spinal cord extends from C1 in the neck
to the lower border of L1
The cauda equina extends from the end of the cord
down to S5 within the sacral canal.
Paraplegia arises from disorders affecting
the thoracic spinal cord and the cauda equina,
whereas
quadriplegia or quadriparesis arises from
disorders affecting
the cervical cord
disorders of the spinal cord result in a spastic
Paraplegia
While disorders of the cauda equina result in a
flaccid Paraplegia

52
COMPRESSIVE CAUSES

Classified as being either extradural or subdural
in site
on neuroimaging (CT/MRI)
Subdural includes those arising from
either within the spinal cord (intramedullary)
or those arising outside the cord
(extramedullary)
Main compressive causes in Africa are
Potts disease and metastatic malignancy,
both of which are extradural.

53
POTTS DISEASE

Paraplegia arise from direct Tb infection of
spinal cord or meninges
The most common cause in
childhood, adolescence and in young adults.
Haematogenous spread of the tubercle bacillus
from pulmonary infection.
The paraplegia occurs either at the time of the
primary infection
or more commonly 3-5 years later by reactivation.
Affecting the intervertebral disc space and
adjacent vertebrae

54
Clinical features of Potts disease

History of localised back pain, over weeks or
months,
worse by weight bearing and followed by a slowly
progressive paraplegia.
Uncommonly accompanied by fever, sweating and
weight loss
The lower thoracic and the lumbar spine are
commonly affected.
Local tenderness and the presence of any
deformity,
particular a gibbus formation
caused by collapse and anterior wedging of
adjacent vertebrae.

Laboratory findings of Potts disease includes
high ESR with typical spinal x-ray changes
a characteristic loss of the disc space at the
site of infection with destruction
and eventually wedging of adjacent vertebrae
paravertebral soft tissue swelling
A CT scan of the spine may also be helpful,
in early disease when plain X-rays may be normal.
Chest X-ray to exclude active pulmonary
tuberculosis.
a needle biopsy
confirming the presence of acid fast bacilli
this is diagnostic.

The standard antiTB treatment for spinal TB
is for a total of 18 months, however a shorter 12
month course has been recently recommended. STG
Surgical intervention
decompression of the cord and stabilization of
the spine
Prognosis with treatment mortality rate is
between 10-20
and full recovery rates of from 25 to 40.

57
SPINAL CORD TUBERCULOSIS

Direct infection of the spinal cord with TB
presents clinically
either as an acute myelitis developing over days
or as a chronic radiculo-myelitis occurring over
weeks to months.
The paraplegia is mostly lower motor neurone
or flaccid in type with absent or depressed
reflexes
with urinary and faecal incontinence.
Tuberculoma of the cord TB meningitis may also
arise from a source of infection within the
spinal cord
screened for HIV infection in all pt with
paraplegia

58
TUMOURS

Primary spinal cord tumours are very uncommon,
arising from the cord, roots or meninges,
affecting all age groups
evolving more slowly over months or years
Metastatic malignancy most common cause of
Paraplegia in the elderly(gt50 years)
developing over a short period, usually days or
weeks
prostate and breast are the most common primary
sources
others are lung, kidney, lymphoma and multiple
myeloma
They are mostly located extradurally
commonly affected the thoracic followed by the
lumbar spine.
paralysis is usually painful flaccid with a
sensory level on the trunk

DIAGNOSIS
suspicion of a malignancy with plain spinal
x-rays
showing lytic or blastic lesions or vertebral
collapse
CSF may sometimes show a high protein level and
yellow discolouration
Neuroimaging (CT/MRI) of the spinal cord
Treatment includes steroids, analgesia,
radiotherapy chemotherapy
The prognosis for metastatic spinal cord tumour
is generally poor

60
ACUTE EPIDURAL ABSCESS

Medical emergency which requires urgent treatment
subacute painful paraplegia occurring over hours
or days
Occur in debilitated patients with diabetes,
alcoholism or renal failure
even healthy person.
can also affect all age groups.
Staphylococcus aureus being the most common
organism
skin abscesses and boils are sources of
infection.
Presents with very severe pain, sometimes
radicular,
and local tenderness at the site of the epidural
abscess
/-fever and signs of infection with or without
meningism.

INVESTIGATIONS
elevated WBC (neutrophil count) and ESR
CSF examination may reveal the presence of a few
white blood cells
and elevated protein level or be normal.
Lumbar puncture should not be performed near the
suspected abscess site
Avoid spread the infection to the CSF and causing
meningitis.
Diagnosis is confirmed
by contrast enhanced CT/MRI spinal cord show
epidural enhancement
Treatment is i/v antibiotics (include
cloxacillin) up to 6 weeks
High dose intravenous steroids during the first
week or two
sometimes surgery decompressive laminectomy may
be indicated

62
NON COMPRESSIVE CAUSES OF PARAPLEGIA

Transverse myelitis,
HIV,
TB,
schistosomiasis,
syphilis,
B-12 deficiency
and HTLV-1( HUMAN T CELL LYMPHOTROPIC VIRUS TYPE
1)

63
TRANSVERSE MYELITIS

Affects mainly young middle aged persons
Episode of inflammation affecting the spinal cord
which results in an acute paraplegia
It is considered to be infectious and autoimmune
in origin,
Also viruses are identified -herpes zoster,
herpes simplex, HIV and HTLV-1
But mostly unknown cause
Paraplegia occurs over hours or days
with initial flaccidity, sensory level bladder
and bowel incontinence

CSF may show elevation in leucocytes and protein
MRI/CT scan of the spinal cord useful to exclude
other causes
Treatment antiviral medication iv steroids
Acyclovir 10 mg/kg (800 mg) iv/po/3-4 times daily
for 10 days
High dose steroids
methylprednisolone 1000 mg iv daily for 5 days
followed by oral prednisolone 60 mg daily,
tapering over 2-3 weeks.
High dose dexamethasone, 24-32 mg daily can also
be used
if methylprednisolone is unavailable.

65
HIV

Paraplegia is a major but uncommon neurological
complication in HIV
main mechanisms are opportunistic infection
direct HIV infection of the cord
Includes TB, viral infections syphilis
vacuolar myelopathy arises from advance HIV
infection of cord
causes paraplegia in lt1 of pts
Management is by treating the underlying cause
by starting ART

66
KONZO

Konzo is a distinct form of tropical
myeloneuropathy
group of paraplegias and peripheral neuropathies
nutritional in origin
characterized by abrupt onset of a non
progressive
but permanent spastic paraplegia related to
cassava consumption.
In epidemics as many as 1-30/1000 persons are
affected
mainly growing children and fertile women
abrupt onset in lt 1 week
The cause of konzo has been attributed to the
combined effect of months
of high cyanide and low protein (methionine and
cysteine, sulphur based amino acids) intake
from exclusive consumption of insufficiently
processed bitter cassava
Instead of safe processing
hydrolysis or soaking in water, crushing and
fermentation or sun drying which takes weeks