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  1. 1. Prepared By-Dr. Md NazrulIslamMBBS, M . sc. (BM E).
  2. 2. HISTORY :
  3. 3.  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.
  4. 4.  Respiratory rate : 16 per min. Temp : Normal. Koilonychia : Absent. Leukonychia : Absent Neck gland : Not palpable. Lymph node : Not palpable. J.V.P : Not raised . Thyroid gland : Not palpable. Skin pigmentation : Absent.
  5. 5. EXAMINATION OF THE NECK: Inspection : There is no swelling or deformity . Palpation : Tenderness present over cervical spine. Local temperature normal. There is no enlarged lymph node & thyroid gland. Movement : (movement of the Cervical Spine ) Flexion – painful & restricted Extension – painful & restricted Lat flexion – painful & restricted Rotation – painful & restricted.
  6. 6. COMOTOR SYSTEM : 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.
  7. 7. LOOKSwelling and deformity over themiddle part of the left leg.Tenderness present.Abnormal mobility in deformed area.Skin condition over the deformed areais normal. No discharging sinus. No vascular deficiency.FEELTenderness present.Temperature slightly raised.Peripheral pulses intact.
  8. 8. Examination of the left lower limb:MOVEMENTLeft knee – joint movement can not be elicited dueto 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 FlexionNormal in passive week in active movement. Adduction --- normal Adduction --- normal
  9. 9. Systemic Examination :Higher psychic function --- normalAll cranial function --- normalMotor functionGeneralized muscles wasting of both upperand lower limbs.Palpation – Bulk of muscle – wasted tone of the muscle – Increased Perianal Sensation – normal Anal tone – present. Cremasteric reflex – present.
  10. 10. Systemic Examination :Regarding muscle powerUpper limb – Shoulder (left &Rt) – Flexion – 4Extention – 5 Abduction - 5 Adduction - 5ELBOW (left &Rt) – Flexion -5Extention -4WRIST (left & Rt.) –Flexion – 4Extention – 4Hand (left &Rt) Grip -Weak 4Finger adduction & Abduction- 4
  11. 11. Systemic Examination :Sensory and Motor: 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.
  12. 12. 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 - 5Ankle (Rt & Lt) - Planter Flexion – 5 Dorsiflexion – 5Toe extensor and toe flexor (Rt. & Lt.) - 4+Sensory funtionof lower limbs- diminished.
  13. 13. Systemic Examination :Alimentary System Inspection – No abnormality detected Palpation – not tneder Auscultation – Bowel sound present P/R – Anal tone – present.Respiratory System Inspection – Normal in size and shape of the cheast. Resp. rate – 16/mint. Palpation – Tachea – Centrally placed Normal cheast expansibility. Percussion – Resonance Auscultation – Bronchial breath sound with no added souund.
  14. 14. Systemic Examination :Cardio-Vascular SystemPulse – 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 presentover precordiuamAuscultantion- S1 and S2 audible.Genito – urinary systimThe patient unable to pass urine normally andthe patient is in Cathder.
  15. 15. Salient Features: Md. Kanu, Aged – 40yrs. Coming from adaber–10, Mohammadpur, Dhaka, admitted on 08.08.11 in S.S.M.C.H with the complains of -  Weakness of the both Upper and lower limb and enability to move.  Difficulty inn passes of urine and stool.  Fracture of the left leg following RTA – 2 weeks back. At this stage he was unable to stand and walk. His upper limbs were so weak that he can not grip anything. He is on Catheter as he could not pass urine. His Facial injury at the chin was healed up. There is a swelling and deformity at the middle of lower leg which is immobilized with bamboo – sticks by kobiraj.
  16. 16. 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.
  17. 17. 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.
  18. 18. Salient 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).
  19. 19. ProvisionalDiagnosis- ??
  20. 20. Provisional Diagnosis-Incomplete CervicalSpinal injury (At C4/C5)(Central cordSyndrome)with fracture Left tibia &fibula.fibula
  21. 21. Differential Diagnosis -• Anterior cord syndrome• Brown – Sequard Syndrome.
  22. 22. Investigations:E.C.G – within normal limitBlood – 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
  23. 23. Investigations:X-ray cheast – N.A.DX-ray Cervical Spine – Lose of lordosisC4/C5 – post. Listhesis (Grade -1)Degenerative change – in all CervicalSpineX-ray left leg – Comminuted fracture of the middle of the shaft of the left tibia and oblique fracture of the proximal fibula.
  24. 24. Investigations:MRI- M.R.I Cervical Spine -  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.
  25. 25. Confirmatory diagnosis- . Incomplete Cervical Spine injury at C4 –C5 level,with Quadriparesis (Central cord syndrome) and Closed comminuted fracture of left tibia and fibula.
  26. 26.  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.
  27. 27. Final follow up– After 2 month.Gait – Patient can stand and walk withsupport.Muscle power (MRC Scale) – 4Active movement of the4 joints of the limb –Almost Normal.Griping power of the hand increased so thathe can eat himself.Bulk of the muscale – improvedJerks are still – exagratedClonus – Absent For fracture tibia –fracture is uniting.But the patient is still unable topass urine without catheter, but can passstool voluntarily. 34
  28. 28. InceptaPharmaceutical,Dhaka, Bangladesh.