23year old male with paraparesis

23year old driver with complaints of paraparesis

i've been given this case to solve in an attempt to understand the topic of "patient clinical data  analysis" to develop my competency in reading and comprehending clinical data including history,clinical findings,investigations and comeup with a diagnosis and treatment plan.

Following is my analysis of patient's problem

chief complaints of the patient:
the problems in order of priority are
 1)weakness of bilaateral lower limbs associated with tingling and numbness since 5 days
 2)vomitings 5days back 3-4 episodes non projectile, non bilious,food particles is content
 3)when he got up for urination ,suddenly he had a fall and got up with the help of father
 4)gluteal abscess since 5 months
 5)scrotal abscess since 20days

as described by patient ,there is initially paraparesis that gradually developed inti paraplegia

causes of paraparesis
1)pvd
-A sudden falll may be due to vascular cause i.e stroke or ischemia or infarcts in the brain.this is ruled out as there are no signs of pain,claudication,skin changes in leg.

2)vitamin b12 deficiency-this is ruled out as there is no anemia

3)injury-ruled out as there is no h/o trauma

4)neuromuscular problem-as there is tingling and numbness there may be nerve problem

cns examination
-hmf-normal
-patient is conscious oriented to time place and person
-cranial nerves intact
motor system:
                        right                     left
bulk                normal                  normal
tone
         UL         normal                  normal
         LL         hypotonia            hypotonia
power
         UL        5/5                             5/5
          LL        2/5                            0/5
reflexes
   superficial reflexes
                     right                          left
corneal          p                                 p
conjunctival  p                                 p
abdominal     p                                 p
plantar           extensor                   extensor

deep tendon reflexes
                     right                           left
biceps           2+                              1+
triceps           2+                              1+
supinator       3+                               2+
knee               3+                             2+
ankle             3+                              2+
jaw jerk         1+                              1+
ankle clonus  present                      absent

primitive reflex-absent
involuntary movements-absent
meningeal signs-absent
-from the above findings it is evident that there is
b/l hypotonia-suggestive of lmn lesions
hyperreflexia of knee and ankle suggestive of umn lesion above l3,l4
ankle clonus suggestive of umn lesion above s1,s2

investigations done-MRI of spine

Vomitings
these vomitings are due to intracranial space occupying lesions which causes raised intracranial pressure and vomiting

investigations done-MRI of brain
gluteal abcess and scrotal abcess are cold abcess as there is no signs of inflammation

interpretation of investigations
-there is significant enhancemnet which represents meningeal enhancement or exudates and following lesions in mri with multiple nodules in pulmonary apices suggest of pulmonary kochs and disseminated tuberculosis.

discussion:
-anatomical location of the cause is most likely at level of l3,l4.
-there may be lesion involving more than one level since the patient has features of both UMN and LMN lesions.
-etiology can be due to disseminated TB
pott's paraplegia is yet to be evaluated and ruled out
-pathologically cause may be due to cold abscess caused by mtb extending to more than 1 level

therapeutic options
-medical management -ATT+rest

surgical management 
-anterolateral decompression