A 22 year old female from thipathi came with c/c unable to pass the urine

N.lavanya 

Roll  93 

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A 22 yr old female from Tipathi , farmer by 

occupation 

came  to the opd with 

Chief complaints  

Fever since  10 days

Head ache since 7  days 

Unable to pass the urine since  2 days . 

History of presenting illness: 

Patient was apparently assymptomatic  10 days

And developed    Gradual onset High fever with 

chills and rigor continuous  associated with 

nausea , relieved on medication 

she had c/o Headache , diffuse in 

region , occipital region predominantly, Gradual

 in onset , dragging type , radiating to neck , 

Aggrevated on talking , rotating the head , 

relieved on medication 

c/o urinary retention ( acute )  for 2 days 

 Able to feel the fullness of bladder , not able to 

pass urine , relieved after passing foleys 

Had Weakness of lower limbs for 4 days . 

Spontaneously resolved . 

- patient was not able to walk on her own during

 the weakness episode 

- No seizures

Past History:

The patient had a similar episode one year back 

She had  high grade fever  for one month gradual 

onset continuous type associated with head ache 

nausea weakness of the limbs and blurring of vision 

Symptoms relieved on medication 

 

 5 days after the  onset of the fever patient  was 

unable to pass the urine  for 2 days and had an 

episode  of 

Altered Sensorium which lasted for 5 mins . Not 

able to recognise persons , place, time . 

Past history:- 

Not a k/c/o DM, Asthma , Epilepsy , HTN 

 

 Menstrual History : 

Personal history:- 

Married female 

Appetite - decreased , improved since yesterday 

Bowels- Constipation , relieved on medication 

Micturition- abnormal 

Addictions:- No addictions

Family history:- Not 

    

  

General examination 

Well informed consent is taken. Examined in a well lit room.

Patient is conscious coherent and coperative well oriented to time place and person.

Moderately built and moderately Nourished. 

 

Vitals : 

Afebrile

BP 110/80mmhg

PR 84bpm

Respiratory rate 15 cpm

 There is no icterus, clubbing, cyanosis or lympathadenopathy,Pedal Edema.

Mild pallor was seen

  

Systemic examination : 

Abdominal examination

Inspection 

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

Palpation : 

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly

  

 Percussion : 

  

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly

   

Auscultation: 

 

Bowel sounds  heard 

CVS examination 

 Inspection:

 

Chest wall - bilaterally symmetrical 

No dilated veins, scars, sinuses 

palpation :

•Apical impulse is felt on the left 5th intercostal space 1cm  

medial to mid clavicular line.

No parasternal heave, thrills felt 

Auscultation : 

•S1 and S2 heard , no added thrills and murmurs heard.

 

Respiratory examination 

Insection 

•Chest is bilaterally symmetrical

Trachea – midline in position.0

Apical Impulse is not appreciated 

Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

palpation : 

•Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated  

percussion : 

The following areas were percussed on either sides- 

Supraclavicular-resonant

Infraclavicular- resonant

Mammary- resonant

Axillary- resonant

Infraaxillary- resonant

Suprascapular- resonant 

Infrascapular- resonant 

 

interscapular - resonant.

  

CNS examination:

Higher mental functions 

Oriented to time place and person 

Immediate memory:Intact

Short term memory:Intact

Longterm memory:Intact

No delusions and hallucinations.

Cranial nerve examination :

 NORMAL

-Olfactory nerve(I): Smell is intact 

-Optic nerve(II):size of both pupils equal.

Pupil reactivity to light:present 

Direct and indirect light reflex are present in both eyes.

-Oculomotor(III),Trochlear(IV)and Abducens(VI):ocular movements present.No 

diplopia,No ptosis,No Horizontal Nystagmus

-Trigeminal(V): Sensations over the face present.

Corneal reflex:present 

Jaw jerk: present

Muscles of mastication:Normal(No wasting)

-Facial nerve(VII): No deviation of mouth

The wrinkles on both sides of forehead are present.

Taste:intact.

Secretions:Normal in eyes.

-Vestibulocochlear nerve(VIII):Hearing intact.

No positional vertigo and nystagmus.

-Glossipharyngeal (IX) and Vagus(X): uvula is centre and pilatoglossus pillars are 

normal and gag reflex intact.

Taste sensations from posterior tongue is normal.

-Spinal accesory(XI):Trapezius and Sternocleidomastoid normal.

-Hypoglossal(XII): Tongue (opening )central in postion.

No weakness and wasting of tongue.

Tongue moments normal.

Neck stiffness:- No 

Kernig sign :- No

Sensory examination: 

                                 Right          Left

Spinothalamic

Crude touch              +                      +

Pain                          +                      +       

Temperature             +                      +

Dorsal column

Fine touch              Lost in bilateral soles

Vibration

Olecranon p            6s                        5s

Styloid process       7s                        10s

Tibia                        4s                        8s

Medial mallelous     6s                        10s

Motor examination:

Tone.       :-         Right.        Left

 Upper limb.      Normal.  Normal

Lower limb.      Normal.   Normal 

Power.             Right            Left

 Upper limb.     5/5.               5/5

 Lower limb.      5/5.              5/5

   

Reflexes.         :-      Right        Left

   Biceps.              +                 +

   Triceps             +                 +

  Supinator.           -                -

   Knee.                ++             ++

   Ankle.               ++             ++

   Plantar.            Flexor      Flexor

 

Lower limb examination in detail, done to localise anatomy of lesion:

  Power.                                                 Right            Left

HIPS 

ILEOPSOAS (L1-L3)                           5/5                 5/5

ADDUCTOR FEMORIS (L5-S1)         4-/5                 4-/5

G MAXIMUS (L5-S1)                          4-/5                 4-/5

G MEDIUS, MINIMUS (L2-L3)           4-/5                 4-/5

THIGH

HAMSTRINGS (L4-S1)                          4-/5                 4-/5

QUADRICEPS (L3-L4)                           4+/5                 4+/5

ANKLE

TIBIALIS ANTERIOR (L4-L5)                4-/5                 4-/5

TIBIALIS POSTERIOR (L4)                    4-/5                 4-/5

PERONEI (L5, S1)                                    4-/5                 4-/5

GASTROCNEMIUS (S1)                          4-/5                 4-/5

FOOT, GREAT TOE 

EXT. DIG. LONGUS (L5)                4-/5                 4-/5

FL. DIG. LONGUS (S1, S2)             4+/5                 4+/5

EXT. HAL. LONGUS (L5, S1)          4-/5                 4-/5

EXT. DIG. BREVIS (S1)                    4-/5                 4-/5

- No finger nose in coordination 

- No knee - heel in coordination

 Investigations:

Hemogram:

Hb: 9.3 gm%

TLC: 6700

PCV: 29.8

MCV: 71.0

MCH: 22.1

MCHC: 31.2

RBCs: 4.20 millions/cumm

PLT: 3.63 laks/cumm

ECG

USG ABDOMEN AND PELVIS

Provisional Diagnosis:

LMN Type Neurogenic Bladder

?Recurrent Transverse Myelitis

?Neuromyelitis Optica Spectrum Disorder

 Treatment 

Ophthalmology opinion was taken for this patients.

Impression: Normal fundus study.

Advice: 

1.E/d  LUBREX 5 times/day

2.Use glasses(Myopic glasses)

Neurology opinion was taken on 29/6/2023

and she adviced-

1.Inj.METHYLPREDNISOLONE 1gm in 100ml of NS once a day for 5 days.

2.Inj.Pantocid 40mg OD/BBF for 5 days at 8 AM

3.Tab.AZORAN  25 mg once daily at 2 PM

4.E/d  LUBREX 5 times/day FOR 5 days  

progression 

We started giving 1gm METHYLPREDNISOLONE in 100 ml of NS under observation, And on the 3rd day she passed urine(Foley's catheter was removed)