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Tumelo Imran Modutlwa - Myelitis Sequela

Author Julia Views Posted at 2014/01/14

Name: Tumelo Imran Modutlwa
Sex: Male
Country: Botswana
Age: 4
Diagnoses: Myelitis sequela, urinary tract infection (healed)

Admission Date: 2012-02-29
Days Admitted to Hospital: 28
Medical History:
When Tumelo was 2 years and 3 months old, he suddenly came down with a serious fever. He cried often and his parents brought him to their local hospital but there was no clear diagnosis given at that time. He was given medication to reduce the fever and soon after, weakness developed in the legs. Tumelo was given an MRI of the spinal cord which revealed abnormal signals in the spinal cord segments T3-T1. He was diagnosed with acute myelitis 4 weeks after the onset of the symptoms. The medication Tumelo was prescribed was largely ineffective. There was paralysis in the legs and sensory impairment.

Admission PE:
Bp: 90/60mmHg; Hr: 90/min, Br: 19/min, temperature: 37 degrees. Height: 110cms, weight: 17.5Kgs. The development and nutrition were normal. The skin and mucosa were intact, with no yellowish discoloration on the skin or petechia. The thorax was symmetrical. Through auscultation, the respiratory sounds in both lungs were found to be clear with no signs of dry or moist rales. The heart sounds were strong, but the cardiac rhythm was irregular. There was no murmur in the valves. The abdomen was smooth and soft. The liver and spleen were not palpable under the ribs. There was no edema in the lower limbs.

Nervous System Examination:
Tumelo was alert and in good spirits. His speech was clear. His memory, calculation abilities and orientation were normal. Both pupils were equal in size and round, the diameter was 3.0mms. Both eyeballs could move flexibly and the pupils reacted normally to light stimulus. The binocular vision was normal through coarse measure. The forehead wrinkle pattern was symmetrical. The tongue was centered in the oral cavity and the teeth were shown without deflection. There was no air leakage when the cheeks were expanded. The movements of the neck were normal. The muscle strength of both upper limbs was level 5; the muscle strength of both lower limbs was level 0. The muscle tension of both upper limbs was normal. The muscle tension of both lower limbs was low. The tendon reflex of both upper limbs was normal. The patellar tendon reflex of both lower limbs was not elicited. The left Achilles tendon reflex was active, the right Achilles tendon
reflex was almost normal. Both feet were presented with ptosis. The bilateral abdominal reflex was not elicited. Tumelo couldn��t cooperate with the examination of the deep or shallow sensation. There was obvious pain when the doctor put pressure on the thoracic vertebrae 3-4 segments. The shallow sensation below the thoracic vertebra segment 4 was diminished. The scratch test below the bilateral thoracic vertebra segment 3 was positive. The bilateral Hoffmann��s sign was negative. The sucking reflex was negative. The bilateral Babinski��s sign was neutral. Tumelo could finish the rapid rotation test and digit opposition test in a stable manner. He was unable to finish the heel-knee-shin test.

We initially gave Tumelo a complete examination, and he was diagnosed with myelitis sequela. He received treatment to expand the blood vessels to improve the blood circulation in order to increase the blood supply to the damaged neurons and to nourish them. This was combined with physical rehabilitation training. After the admission, the urinalysis results showed an infection and Tumelo received antibiotics intravenously.

The urinalysis results were normal. The bilateral patellar tendon reflex was able to be elicited. The left side Babinski��s sign was negative; the right side Babinski��s sign was neutral. The left lower limb could bend and support the body, but only for a short amount of time. There were slight muscle contractions in the lower limbs when the toes of both feet were stimulated. The muscle strength of both lower limbs can reach between level 1 and level 2. The control over the hips has improved.


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