Prefinal
Timeline of events
24/M - with a daily routine of getting up in the morning , bathing, eating food prepared at home reluctantly consisting of only curd and half a chapathi, refuses to take spices, meat,vegetables, followed by picking up cowdung 2-3 hours a day. After which he rests for an hour or two in the afternoons , and tends to the cows till evening, this involves taking them to a field 3kms away from home by walk and bringing them back.He interacts with his family and describes his daily events in the day followed by dinner and sleep...with intermittent 2-3 times a week , bedwetting in the night.
He also has a liking for particular sweet which he buys with the exact money given to him at home, from a shop nearby.
After getting discharged here, family has to take care of his dressing , and take effort to keep the central line dry, change his diaper once he informs them that he passed stool without his knowledge.
General examination:
Built: thin, poorly nourished
Pallor+
Motor examination on 15/03/22
Gait :15/03/22
Examination:systemic
HIgher mental functions
Right handedness
LOBAR
1)Frontal lobe:
Executive function: no planning: asked why and how he came to the hospital, randomly does his daily activities .
no judgement:
no abstract thinking: no understanding of meaning of
eg.movies, words spoken, sayings
no motor sequencing :only 2 step commands
working memory: digit span: could repeat only upto 3
normal is 7+/-2
appropriate dressing sense+, no aggitated outbursts
2)Parietal(dominant)- left
no right left disorientation
finger agnosia-non verbal finger recognition+
identification of named finger +
praxis:
ideational apraxia-could close his urine bag cap
buttoning and unbuttoning of shirts+
calculation: subtraction,addition, upto 2 table multiplication
language:speech: spontaneous,comprehension+, repetition+naming+, no reading/writing
non dominant-right
visuo spatial orientation -can navigate from home to the field and a shop
constructional: not willing to draw
temporal:
memory:able to recollect what he had for breakfast, events from morning to night.
occipital
vision:no visual agnosia/prosopagnosia
cranial nerves:
1- olfactory: intact
2-optic- acuity-normal
field - normal
colour: normal
3,4,6- extra occular muscles -N
pupillary:direct and indirect+
5: sensation over face+
corneal,conjuctival,jaw jerk+
7: no deviation ,
8-normal
9,10-uvula and palatal arch movements-normal
11-trapezius and scm movement-normal
12-no deviation of tongue,or fasciculations
motor:
tone: upper limb. lower limb
Rt. normal. normal
Lt. normal. normal
power:. right. left
upper limb
proximal. 5/5. 5/5
distal. 5/5. 5/5
handgrip. 80%. 80%
lower limb.
proximal. 5/5. 5/5
distal. 5/5. 5/5
trunk : no beevor's sign
neck: able to flex extend
reflexes:
biceps. 2+ 2+
triceps. 2+. 2+
supinator. -. -
knee absent. absent
ankle. absent. absent
plantar. mute. mute
abdominal. present. present
cremasteric. present. present
anal : contraction of anal spincter+
sensory:
cortical:2 point discrimination+
stereognosis+
tactile localisation+
tracts:
spinothalamic-pain. present. present
crude touch
temp
posterior column: present in all dermatomes
fine touch
, position sense,
rhomberg's negative
(no saddle anaesthesia)
cerebellum:
tandem walking-couldnt be done
gait normal : intiation, maintenance,stance width, step length,height, arm swing, fluidity, speed-normal
tremor+ in b/l hands
no nystagmus
no rebound
able to do finger nose ,finger finger test
kneel heal
no dysdidokinesia
autonomic:
bladder:able to perceive fullness, pain+
unable to void
dribbling intermittently
bowel: not able to perceive fullness
able to perceive after passing stool
cranium-normal
Spine: kyphosis +
cvs: insp:jvp couldnt be visualised
palpation:apex in 5th ics medial to midclavicular line
parasternal heave +
auscultation:no murmur
r.s :inspection:normal on both sides
palpation:normal on both sides
percussion:normal on both sides
auscultation : normal on both sides
diagnosis: neurological:subacute retention of urine
Bowel incontinence
anatomical: lmn type of neurogenic bladder with overflow incontinence
no constipation but loss of sensation of passing stool-
with frontal lobe -loss of executive function
course: intermittent, resolving
acute-subacute: ? demyelination ?hypoxic brain injury.
Investigations:
Xray pyelography 3 years back
No calculi
Bladder wall -abnormality
Usg: 3 yrs back
B/l gross hydroureteronephrosis with thinned out cortex.
Urea-89
Creatinine-4mg/dl
Hb-11.1gm.
09/03-
Blood urea: 175 mg/dl
Serum creatinine : 9.3 mg/dl
Abg:
PH :7.2mmhg
Pco2:7.8mm hg
Po2:123 mmhg
Hco3:1.0
Hrct on 11/03/22
Chest:
Peripheral consolidation with central translucency in right lower lobe.
Xray on 9/03/22
Final diagnosis:
intellectual disability secondary to ?birth asphyxia
with acute (resolved)on chronic renal failure secondary to bladder outlet obstruction
subacute lmn Neurogenic bladder
non healing ulcer of right foot
With cavitary lesion on right lowerlobe? Fungal
Discussion:
1)Neurogenic bladder
https://www.urozoone.com/neurogenic-bladder/
Lesion causing urinary retention with overflow incontinence-lmn type bladder
Lesion at level of s2-s4 which is uninhibited internal spinchter contraction and dertrusor underactivity.
2)Neurogenic bladder causing hydroureteronephrosis
Case presentation
A 19th years old male with neurogenic bladder, VUR grade 4, CKD stage 4, malnutrition, and short stature. Radiological examinations show a spastic neurogenic bladder, cystitis, right VUR grade 4. Abdominal ultrasonography (USG) results were bilateral severe hydronephrosis due to post-renal causes. This patient had a history of myelocele excision at the age of 1.5 years. He had recurrent urinary tract infection with CKD stage 4.
3)why nocturnal enuresis is lmn bladder?
4) infection in ckd
Information collected from the following blog:
https://warshasukeerthirollno64.blogspot.com/2022/03/24-yr-old-male-with-acute-kidney-injury.html
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