2. Particulars of the patient
Name – Md. Mokbul Hossain
Age – 42 years
Sex – Male
Address – Sadar, Munshiganj
Reg – 208012
Ward – NB, Bed – 739
Date of admission – 13/10/22
3. Presenting complaints
• Pain in the neck and lower back region for 6
months.
• Difficulty in walking for 6 months
• Weakness & clumsiness of right hand for 6
months.
4. History of present illness
According to the statement of the patient he was reasonably well 6 months
back. Then he developed pain in the neck and lower back region following a
fall in the bank of river. Back pain was initially dull achingin nature, radiating
to the buttock and right lower limb, aggravated by walking and partially
relieved by sitting, leaning forward and taking rest, and gradually increasing in
intensity. Pain was less experienced in walking up stair than down stair. He
also complains of difficulty in walking for 6 months. He also noticed tingling
and numbness in right upper and lower limb. He also complaints of weakness
& clumsiness of his right hand for same duration. He gave no history of fever,
weight loss, cough, hemoptysis. His bowel and bladder habit was normal.
5. • History of past illness : There is no H/O
diabetes, HTN, tuberculosis, asthma or any
chronic disease.
• Treatment history: Taking analgesic & PPI.
• Personal history: Non smoker and alcoholic.
• Family history: No history of such type of illness
in the family.
• Socioeconomic history: Low socioeconomic
status.
6. General Examination
• Appearance : Anxious
• Body built : Average
• Cooperation : Cooperative
• Decubitus : Supine position
• Anaemia : Absent
• Jaundice : Absent
• Clubbing : Absent
7. • Dehydration : Absent
• Lymph node : Not enlarged
• Pulse : 76 / min
• BP : 110/80 mm Hg
• Temp : Normal
• R/R : 18 / min
Systemic Examinations
• No systemic abnormality was observed.
8. LOCAL EXAMINATIONS:
Upper and Lower limbs and spine:
• Loco-regional Examination
• Look :
Neck -straightened.
Cervical and lumber lordosis - obliterated
Visible muscle wasting: Absent
Gait – Broad based, slow,
Squatting- possible with difficulty
Heel walking- Not possible
Toe walking- Not possible.
• Feel :
Temperature: Normal
Tenderness : Absent.
Paravertebral muscle spasm present.
Palpable step: at lumbosacral junction
• Move :
– ROM of lumbar and cervical spine - restricted.
9. Neurological examinations : Upper limb
• Sensory - intact in All dermatome of upper limbs.
• Muscle power ( MRC grade ) :
Elbow flexion (C5)– 5/5
Wrist extensor (C6) -5/5
Elbow extensor and finger extensor wrist flexor (C7) -5/5
Finger flexion (C8)-5/5
Jerks : biceps, triceps and brachioradialis jerks are
exaggerated on the right side
10. Lower limb
• Sensory- diminish lumber 5 dermatome in right side
• Muscle power- MRC grade - Extensor hallocis longus
– 3/5 in right side and other group of key muscle are
-5/5
• Knee jerk – exaggerated in right side
• Ankle jerk- exaggerated in right side
• Planter reflex- extensor in right side
• Clonus – ankle and patella clonus – Present
• Tone: Spastic
11. Upper limb
• Spurling test : Positive
• Hoffmann’s sign: Positive
• Finger escape sign- Positive
• Finger fatigue sign –Positive
• Lhermittes test: Positive
Lower limb
• Straight leg raise test- right– 80 and left –70
• Cross SLR – negative
• Bowstring test- negative
• FABER test- negative
Special test
24. Diagnosis:
Cervical myelopathy due to Prolapsed
intervertebral disc at the level of cervical 3-
4 with Lumbar canal stenosis due to
spondylolisthesis at the level L5-S1
25. Unit plan
ACDF for cervical spine (Now) and PLIF for
spondylolisthesis (Later)
