SPASTIC QUADRIPARESIS-MND vs MYELOPATHY

A 45 year old male patient,agricultural labourer by occupation presented to the KIMS General Medicine OPD with the complaints of difficulty in standing up from sitting position since 6 months and history of weakness in the upper limbs hindering his daily activities since 5 months.

He was apparently asymptomatic 6 months back then he developed proximal muscle weakness in the lower limbs,initially in the right lower limb followed by left lower limb. He had difficulty in getting up from sitting posture and he also complained of tightness initially in the right lower limb followed by the left.
After a month, he had difficulty in performing his daily activities with both his hands such as holding the instruments for work on the field. He says this was followed by his inability to lift his left hand above his head initially followed by weakness even in the right hand.
He gives history of slippage of footwear since 3-4months and also He is unable to button and unbutton his shirt since 2 months.
He doesnt give any history of loss of consciousness, seizures, giddiness, bowel/bladder incontinence,cranial nerve anbormalities,paresthesias in the limbs.

Past history:Not a k/c/o Hypertension,Diabetes mellitus,Thyroid disorders,pulmonary kochs,epilepsy,asthma.

Family history:No history of similar complaints in the family.
Not a k/c/o Hypertension,Diabetes mellitus,Thyroid disorders,pulmonary kochs,epilepsy,asthma.

Personal history:
Mixed diet
Appetite adequate.
Bowel and bladder regular
No sleep disturbances present.
Chronic alcoholic since 10 years.
Non smoker

General physical examination-
Patient is lying supine on the examination couch.
Temp-98.6F
Heart rate- 60bpm,regular on right radial artery
Blood pressure: 120/80mmhg in supine posture on right arm
No pallor,icterus,cyanosis,lymphadenopathy,clubbing,koilonychia,pedal edema.
All the peripheral pulses felt.

General systemic examination:

Central nervous system examination:

Patient is a right handed person and has a wide based stance.
Gait is noted to be a Scissoring gait.

Higher intellectual function are intact.

All the cranial nerves are intact.

 Motor system:

 NUTRITION:
Wasting of thenar and hypothenar muscles in both the upper limbs.

 TONE:
Hypertonia in both the upper and lower limbs.

 POWER:
4/5 in the upper limbs.
3/5 in the lower limbs.

 REFLEXES:
Superficial reflexes: Corneal and conjunctival reflexes present.
                                 Abdominal and Cremasteric reflexes absent.
                                 Anal reflex present.
Deep tendon reflexes: Biceps,triceps,supinator,knee,ankle exaggerated(++++)
Plantae reflex: Not elicitable
Hoffmann's and Wartenburg's sign:Present.

 Patellar clonus:Present

 Ankle clonus:Present.

 Fasciculation seen.

Sensory system:Intact

Cerebellar system:
Finger-nose test:Able to do
Finger-finger test:Able to do
Dysdiadokinesia:Able to do
Romberg's test: Positive

Other systems examination:
Cardiovascular:S1S2 heard,No murmurs.
Respiratory system:Bilateral air entry present,Normal vesicular breath sounds heard.
Per abdomen: Soft,Non tender.
                       No organomegaly,Bowel sounds heard.

Provisional Diagnosis: SPASTIC QUADRIPARESIS UNDER EVALUATION.

 He then underwent all the necessary investigations.






MRI Cervical spine with Whole spine screening was done for this patient.




**Blood samples for Vitamin B12 levels were sent which was 851pg/ml**

**ECG was done which was normal**



Your valuable inputs on this case are highly appreciated

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