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G.Srinu, a 52-year-old male, presented with pain and weakness in both lower limbs for 2 months. Examination revealed decreased sensation below D5 level, grade 2 hypertonia in both lower limbs, and weakness of hip, knee, ankle, and toe flexion/extension graded 1/5 bilaterally. Reflexes were normal in the upper limbs and biceps/triceps, but hyperreflexic in the knees and ankles. Plantar responses were extensor bilaterally. The patient was diagnosed with a D2-D5 OYL with myelomalacia and comorbid hypertension.
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- 1. Name- G.Srinu Age- 52/M Mrd no- 1341010 Diagnosis – D2-D5 OYL with myelomalacia Comorbidities-HTN from 3 years
- 2. • h/o pain and paraesthesia's in both lower limbs for 2 months • h/o weakness of both lower limbs for 1 month • h/o tightness in both lower limbs present • h/o band like sensation over abdomen present • h/o difficulty in rolling over bed present • h/o urinary retention and constipation present • No h/o trauma
- 3. O/E: Patient conscious and coherent Vitals stable -CNS examination Higher mental function-normal
- 4. CRANIAL NERVE EXAMINATION • CN 1: B/L sense of smell normal • CN2: VA right –6/6 and left – 6/6 CN 3,4,6- • EOM full range • No nystagmus • No ptosis • Pupils- B/L 3mm equal and reactive.
- 5. CN 5- Normal CN 7- Intact CN 8 • B/L AC>BC , Weber's not lateralised • CN 9, 10 • Uvula midline • Palatal movements normal ,no asymmetry
- 6. CN 11 • Shoulder shrugging – Normal on both sides CN 12 • No fasciculations of tongue • no Tongue deviation
- 7. Sensory system:Proprioception,fine touch,crude touch,vibration decreased below D5 level Rhombergs sign,tandom gait: CNA Cerebellar signs: Intact No involuntary movements Meningeal signs: no
- 8. MOTOR SYSTEM: Tone • Normal in both upper limbs,grade 2 hypertonia in both lower limbs Bulk • Normal in all limbs(bilateral pedal edema present)
- 9. Power - right left Upper limb Shoulder- 5/5 5/5 Elbow- 5/5 5/5 Wrist- 5/5 5/5 HG- 100% 100% Lower limb Hip- 1/5 1/5 Knee- 1/5 1/5 Ankle- 1/5 1/5 EHL- 1/5 1/5 • Reflexes – • Superficial reflexes-absent • DTR: BJ TJ S KJ AJ Right - 2+ 2+ 2+ 3+ 3+ Left - 2+ 2+ 2+ 3+ + Ankle clonus present Plantars- both extensors