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Rubzzzz's Neurology Case Hx 4th year


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Rubzzzz's Neurology Case Hx 4th year

  1. 1. National O.O. Bohomolets Medical UniversityDepartment of Propaedeutic of Neurology Head of department Prof. Teacher Olena Anatolivna Case report of Alexander Marchenko 56 y.o Student: Group 35 4th year Med 1Date of examination:30/03/08
  2. 2. A) Identifying information • Surname: Alexander Marchenko • Age : 56 y.o • Nationality: Ukraine • Address: Kiev • Occupation : Mechanic • Admission date and time: 16/03/08 14.45 • Diagnosis : RadiculitisB) Chief complaint: - Patient had continuous vertebra pain especially at lumbar region. Pain radiated to right leg. Patient complained about limitation of movement especially during bending and turning. - Sleep only 4 hours due to pain - Headache and weaknessC) Anamnesis Morbi: - In February 2008, patient had a history of dislocation of lumbar nerve due to lining on cold wall for a long time. Patient suffered from pain which later radiated to right leg. Patient couldn’t walk properly so was using stick to support himself. - Patient went through physiotherapy everyday for a week but no effect.D) Anamnesis Vitae - Patient works as mechanic at a theatre and he does heavy works. - Has some family history of CNS disorder. - Suffering from secondary hypertension. - Headache due to weather, smoke and drink occasionally. - Only 2 meals per day. - No allergy.E) Physical examination: 1. General condition of patient • Mood: good • Position on the bed: difficulty due to back ache and limitation of right leg. • Consciousness: clear • Sleep: 4 hours per day due to back ache • Appetite: Normal appetite (3 times per day) • Body constitutional: Normostenic a. Respiratory system - No specific complain. b. G.I system- No specific complain c. Genitourinary system-no back pain. Normal color of urine (light yellow). d. Nervous system and psychic state- Lumbar pain and sleep disorder
  3. 3. e. Sense organs- Myopia, sense of smell is good, no taste disturbance. f. Mucoskeleton system- Lumbar pain and right leg abnormalities g. Cardiovascular system- No specific complain Physical development: • Height: 163.5 cm • Weight: 70.5 kg’s 2. Skin • Skin colour: normal skin color (pink) • Humidity: satisfactory • Elasticity: satisfactory • Rash: absent • Turgor: satisfactory • Edema: absent 3. Mucous membrane • Color: pink colour without any hemorrhage. • Tongue: satisfactory. No specific sign of abnormality. • Eyes: normal color without jaundice. Myopia 4. Subcutaneous layer -Moderate. • Turgor: satisfactory. • Distribution: uniformly • Thickness: satisfactory (2cm) • Edema: absent 5. Muscular system • Hypertonus/ hypotonus: adduction and abduction movements satisfactory except at right leg where patient has some difficulty of moving. • Atrophy: absent • Paralysis and paresis: absent, satisfactory of muscle tonus, absent of Muscular twitching, no arbitrary and also controllable movements of face, trunk and limb muscle except right leg. • Muscle’s force and muscles tones: satisfactory except right leg - Muscles development is satisfactory according to age. 6. Bone system • Size of thorax: Normostenic • Edema: absent • Scoliosis: absent - Patient has lumbar pain and right leg abnormalities7. Joints
  4. 4. • Pain: Vertebra pain especially lumbar region and right leg • Limitation of movement: limitation during bending, turning the body and right leg. • Color: normal skin color, no hyperemia or pallor. • Size: normal size, according to his body built and size. They are not enlarged. • Temperature: The temperatures around his joints are of normal body temperature. • Edema: absent Tendon: Wrist: positive and symmetrical at the dextra and sinister. Painless Knee: right knee is hypo reflex than left knee. Slight pain at the right leg. Elbow: positive and symmetrical dextra and sinister. Painless Ankle: right ankle is without reflex and normal reflex in left side. Painless8. Lymphatic system No abnormalities in any localization of lymph nodes. Lymph nodes are not enlarged.9. Respiratory system • Size of chest: Normostenic. • Rate of breathing: Normopnea. 23 per minute • Rhythm: rhythmic respiration • Type of breathing: thoracic and symmetrical • Passage of breathing: free nasal • Vocal tremor: symmetrical in both sides. Palpation: No abnormality. • Pain; absent • Edema: absent • Protrusion of intercostals intervals: absent • Resistance of thorax: satisfactory. • Pleural rub: absent of the noise by deep palpation Topographical percussion: • Upper border from anterior side: 3cm above the clavicles. • Upper border from posterior side: C7 • Kronig’s area: 4 cm • Inferior border: LINES RIGHT LUNG LEFT LUNG Parasternal V rib - Mid clavicle VI rib - Anterior axillary VII rib VII rib Middle axillary VII rib IX rib Posterior axillary VII rib IX rib Scapular X rib X rib • Excursion of the lungs: 5cm
  5. 5. Comparative percussion: symmetrical and resonance sound. Auscultation sound: symmetrical and without any additional sound. Vesicular sound near alveoli and bronchial sound at the throat and trachea. Cough: absent Bronchophony; satisfactory10. Circulatory system Palpation of apex: weak pulsation. Horizontal line: V intercostal space Vertical line: 0.5cm to the middle from the left midclavicular line Area of apex: 1x1cm Pulse rate: 72 per minute Pulse rhythm: regular Size of pulse: normal size Borders of relative heart dullness: Right border: between right parasternal and right sternal line. Closer to the latter, further called “right sternal line” Upper border: III rib Left border: on the left midclavicular line Transversal heart distance: 11cm. Border of absolute heart dullness: Right border: left sternal line Upper border: IV intercostal interval Left border: left parasternal line Transversal heart distance: 5 cm Auscultation: 1st point: S1 louder than S2 (mitral valve) 2nd point: S2 louder than S1 (aortic valve) 3rd point: S2 louder than S1 (pulmonary valve) 4th point: S1 louder than S2 (tricuspid valve) 5th point: S1 louder than S2 (Botkin Erb’s point) - No additional sound been heard. No murmur. Blood pressure: 112/70 mmhg 11. GI system Inspection:- • Mouth: normal colour mouth (natural light pink) • Mucous membrane: satisfactory colour. • Tongue: light pink colour, damp, clean • Stomach: normal form. Round and symmetrical, size is lower than thorax level, good participation of stomach muscles
  6. 6. Palpation:- • Sigmoid colon: smooth surface, 2cm, soft, mobile, absent of grumbling , painless • Cecum: inactive, 3 cm smooth surface and rather dense but painfull • Shchotkin – Blumberg symptom: negative/painless • Rovsing symptom: negative • Ascending colon: 2cm of thickness, mobile, painful and grumbling. • Transverse colon: umbilicus level, mobile upwards and downwards, soft, without grumbling, 2cm of thickness but painful. • Descending colon: 2cm of thickness, mobility, painful and grumbling • Mendel’s symptom: negative • Liver: soft, smooth surface, sharp margin, tenderness but painful. Gall bladder:- - Kehr’s symptom, Lepine’s symptoms, Mussy’s symptom, Ortner’s symptom, Murphy’s symptom, Boas symptoms are negative. Pancreas:- - Chauffard’s zone, Grott’s method, Desjardin point, Mayo- Robson’s point are negative Spleen symptoms are negative. Percussion:- • Stomach: tympanic resonance sound. Slight abdomen pain (acute) especially near right hypochondrium and epigastric region. • Liver: dullness sound. (Kurlov’s method): - Margin I: 10 cm Margin II: 7 cm Margin III: 7 cm • Spleen: dullness sound at the 10th ribs Fluctuation: no liquid in abdominal cavity Auscultation of stomach:- - Grumbling sounds are present - Lower border of stomach: 2-3cm above umbilicus Stool: Without complain. Once a day without pain. Brown colour and no odor12. Genitourinary Palpation of bladder: painless. Pasternatsky symptom, Obraztsov-Strazhesko, Shelagurov’s, Israel’s, Botkin’s, Hnatyuk’s methods are negative. Percussion: decrease in resonance because of empty bladder. Urine: light yellow colour and satisfactory diuresis. No nocturia
  7. 7. 13. Endocrine system Palpation of thyroid gland: • Pain – painless • Surface-smooth, • Consistency – soft • Mobility – mobile(during swallowing movements) • Pulsation – absent - No abnormality/no disorder.14. Nervous system - All 12 cranial nerves are normal without any disorder. More sympathetic effect than Parasympathetic. I pair : Patient can identify different smell. II pair : Test on the eye ground (both eyes were symmetrical). Field of vision dextra -3 and sinister -3 III, IV and VI pairs : Eyes blinked symmetrically. Absent of ex or enophthalmia,Strabismus and ptosis. Positive reaction to light. Negative sclerosis of eye vessels. Absent of pursuit’s paresis. Argil Robertson and Bernord Horner symptoms V pair : Tactile and sensory of skin is symmetrical in both sides of the cheeks. Good mastication muscle movements. No pain sensation. VII pair : Good mimic muscle movements and symmetrical in both sides of face. The taste sensation of the anterior 2/3 of the tongue is good VIII pair : Balanced. Good hearing according to Weber and Rinner tuning fork test IX and X pairs : No problem with swallowing, speech is clear and normal position of palate. The taste sensation in the posterior 1/3 of the tongue is good. Skin on the abdomen appears tactile and during demography, red lines appears. Symmetry at both sides XI pair : Symmetrical in both sides. He is able to turn head side to side, back and rising. He is able to raise the hands above the horizontal level and absent of m. Sternocleidomastoid and m. Trapezius atrophies and fasciculation. XII pair : Normal tongue position and its movement. Without any atrophies and fasciculation in the tongue muscle. MENINGEAL SYNDROME: - no headache, no vomiting, no nausea and normal sensitivity. MENINGEAL SIGN • RIGIDITY OCCIPITALIS: Negative. No pain. • BABINSKOGO REFLEX : Negative. • KERNIG’S REFLEX : Negative. • BRUDZINKI REFLEX :- a) UPPER REFLEX : Negative. b) MIDDLE REFLEX : Negative. c) LOWER REFLEX : Negative.
  8. 8. MOVEMENT VIOLATION SYNDROME: - Negative and no disorder. • Central (spastic): negative • Peripheral (atonic, flaccid): negative • Hyperkinesias: negativeIMPAIRMENT OF CONSCIOUSNESS SYNDROME: - Clear consciousness and no disorderCONVULSION SYNDROME:- Negative and no disorder • Tonic: negative • Clonic: negative • Tonic-clonic: negativeREFLEX: • Skin reflex: Positive. Muscle movements is symmetrical at dextra and sinister • Mucous : Tongue n swallowing reflex is normal. Symmetrical at dextra and sinister • Eye : Eye blinked. Symmetrical at dextra and sinister • Oppenheim’s : absent • Gordon’s : absent • Schaffer’s : absent • Rossolimo’s : absent • Zhukovsky’s : absent • Bechterew’s : absentTENDON: Wrist: positive and symmetrical at dextra and sinister. Painless Knee: right leg is hypo reflex than left leg. Slight pain at right leg. Elbow: positive and symmetrical at dextra and sinister. Painless Ankle: right ankle is absent of any reflex and left side is normal. PainlessMovement coordination: • Finger – nose : no disorder • Finger – finger : no disorder • Heel – knee : no disorder • Romberg test : steady • Steward – Holms : absentSensory function exam: - Negative Wasserman, Mackewicz, Nery and Dezherine signs. - Positive Laseg sign on right sideVegetative and trophic function exam: - Paleness of skin color on right side of leg and normal temperature
  9. 9. F) Preliminary DiagnosisAccording to complaints:- Patient complains about continuous pain at the lumbar region during bending down and somepain at the right leg.According to anamnesis:- Patient work as a mechanic at the theatre and he bends a lot. Patient also rests his back on thecold wall for a long time. He also had difficulty walking by his own so he used stick.According to physical examination:- In neurological status, palpation in paravertebra points is painful in lumbar region on the rightside, positive Laseg sign on the right side. These results show about damage of the radix L4, L5and S1 on the right side.- According to all mention above, patient is suspected for lumbosacral radiculitis.G) Additional examination - X-ray - Blood analysis - Biochemical analysisH) Result of the additional examination 1. Blood and biochemical analysis RBC 5.22 x 1013 g/L Hb 161g/L WBC 5.4×109 g/L Urea 2.8 mmol/L Creatinine 80 micromol/L Cholesterol 5.5 mmol/L Basophil 0% Eosinophil 3% Band 1% Segment 60% Lymphocyte 20% Monocyte 10% ESR 4 mm/H ALT 0.02 mmol/L AST 0.22 mmol/L Platelet 329 g/L 2. X-ray - Spondolous of lumbar puncture on anterior surface of vertebra. Osteochondrous of L1, L3 and L5. Decrease of intervertebra of L2, L3, L4 and L5.I) Differential diagnosis - Vertebrogenic lumbar ischegia
  10. 10. - LumbagoJ) Clinical diagnosis Main: Vertebrogenic Lumbar Sacral Radiculitis on right side with impairment L4, L5 and S1 Complications: without sensory lesion. Possible intravertebra disk protrusion. Accompanying diseases: NoK) Etiology and pathogenesis of disease - Lumbar radiculitis is an inflammation or irritation of a nerve root in the lower, or lumbar,region of the spine. This irritation can cause by constant sitting on the cold wall and also bendingdown. When radiculitis is present, there is always some degree of pain present. This pain is aresult of pressure on the nerve root (radicle) where it connects to the spinal column (compressionof vertebra disk of radix).L) Treatment of patient - NSAIDs - Epidural injection - Analgesic - Bed restM) Records 25/03/08 - Positive dynamic sign, decrease of pain and increase of reflex. 30/03/08 - Patient can walk without stick.N) Prognosis - Patient became better after medication and he can walk without using stick.O) EpicrisisP) References - Lecture notes - - Neurology and neurosurgery by Walter G. Bradley and Robert M. Crowell