A case of monoparesis

A young adult male presented with monoparesis. A case study. Upper limb progressive monoparesis.

1. “A Young Adult Male with Right sided Monoparesis ” Dr. Md. Mamunul ABEDIN Assistant Registrar Dept. Of Physical Medicine & Rehabilitation Shaheed Suhrawardy Medical College Hospital

2. Particulars of the patient Name : Mr. Saddam Hossain Age : 27 years Sex : Male Marital status : Unm arried Occupation : Service holder Religion : Islam Present Address : Chattogram Date of Admission : 22 .1 1 .2021 Date of Examination : 22 .1 1 .2021

3. Presenting Complaints Right upper limb weakness for 10 months

4. H/O Present Illness Patient states that he was relatively well 10 months back. Then he develops weakness of his right hand which is gradual in onset and progressing day by day. He also noticed wasting of his right upper arm especially at hand and forearm. This weakness is not associated with any pain or numbness. He gave h/o fall on

5. ground with outstretched hand after a high jump 10 months back. On further questioning, he mentioned clumsiness of his right hand on holding a computer mouse for short period of time, and fasciculation which is also progressing slowly over the last 3 years. He has no neck pain, fever, night sweats, weight loss. H/O Present Illness (contd.)

6. For these difficulties, he is having problem with grooming, dressing, holding an object but pen, lifting & carrying heavy objects. H/O Present Illness (contd.)

7. H/O Past Illness • Nothing significant

8. Socio-Economic Condition Patient belongs to middle socio-economic status Monthly income is average 15,000 BDT Lives in semi- pakka house & uses sanitary latrine Drinks boiled water & takes usual Bangladeshi diet

9. Personal History Non - smoker, non alcoholic No habit of chewing betel leaf

10. Psychosocial history He is a practicing Muslim, merely satisfied with his way of living and quality of life Not involved in any kind of litigation

11. Family History Un married Has 2 brothers and 1 sister All of his family members are apparently in good health No h/o similar type of illness or tuberculosis among the first degree relatives

12. Immunization History Patient is immunized as per EPI schedule including BCG vaccination .

13. Drug History He had taken painkillers for short period of time prescribed by local doctors for his trauma Currently t aking no medications

14. Clinical Examination

15. General Examination Appearance : A nxious Body build : Average Co-operation : Co-operative Decubitus : On choice Anaemia : Absent Jaundice : Absent Cyanosis : Absent Oedema : Absent Dehydration : Absent

16. Clubbing : Absent Koilonychia : Absent Leuconychia : Absent Lymph nodes : Not Palpable Neck vein : Not engorged Thyroid gland : Not enlarged Nail changes : Absent Skin : Normal General Exam (contd.)

17. Pulse rate : 78 bpm Blood pressure : 1 2 0/80 mm Hg Temperature : 98.6° F Respiratory rate: 1 4 /min Height : 1. 6 5 m Weight : 5 3 Kg BMI : 19 Kg/m ² General Exam (contd.)

18. Systemic Examination

19. Nervous system Examination : Higher psychic function : Normal Gait : Normal Speech : Normal Signs of Meningeal Irritation : Absent Cranial nerves : Intact

20. Examination of Motor System : Bulk of Muscle s : Right Left Shoulder All groups Normal Normal Elbow Extensor Group Wasted Normal Flexor Group Wasted Normal Hand Thenar Wasted Normal Hypothenar Wasted Normal Dorsal Guttering Present Normal Lower Limbs All groups Normal Normal

21. Examination of Motor System (contd.) :

22. Examination of Motor System (contd.) :

23. Examination of Motor System (contd.) :

24. Examination of Motor System : Right Left Upper Limb Normal Normal Lower Limb Normal Normal Muscle Tone: Ankle Clonus: Absent

25. Power of muscles : Upper Limbs : Right Left Shoulder Abductors 5/5 5/5 Elbow Flexors 5/5 5/5 Extensors 5/5 5/5 Wrist Flexors 5/5 5/5 Extensors ( ECRL ) 4 /5 5/5 Finger Extensors ED 4 /5 5/5 Examination of Motor System (contd.) :

26. Power of muscles : Upper Limbs : Right Left Finger Flexors FPL (Thumb) 5/5 5/5 FDP (2 nd & 3 rd ) 5/5 5/5 FDP (4 th & 5 th ) 5/5 5/5 Finger Abduction 1 st DI 3/5 5/5 Finger Adduction 3/5 5/5 Examination of Motor System (contd.) :

27. Power of muscles : Upper Limbs : Right Left Thumb Abduction 0/5 5/5 Thumb Extension 0/5 5/5 Thumb Opposition 5/5 5/5 Examination of Motor System (contd.) :

28. Power of muscles : Lower Limbs : Right Left Hip Flexor 5/5 5/5 Extensor 5/5 5/5 Knee Flexors 5/5 5/5 Extensors 5/5 5/5 Ankle Dorsiflexors 5/5 5/5 Plant a r flexors 5/5 5/5 Evertors 5/5 5/5 Invertors 5/5 5/5 Great Toe Extension 5/5 5/5 Examination of Motor System (contd.) :

29. Deep Tendon Reflexes : Biceps Triceps Supinator Knee Ankle Right Normal Normal Normal Normal Normal Left Normal Normal Normal Normal Normal Examination of Motor System (contd.) :

30. Deep Tendon Reflexes : Biceps Triceps Supinator Knee Ankle Right Normal Normal Normal Normal Normal Left Normal Normal Normal Normal Normal Examination of Motor System (contd.) :

31. Plantar Reflex : Flexor bilaterally Hoffmann’s reflex : Negative bilaterally Coordination : Normal Examination of Motor System (contd.) :

32. Paper sign : Possible Rock/ Stone sign : Possible OK sign : Possible Ceiling test : Positive Scissor sign : Weak Froment sign : Negative Card Test : Positive Rapid Assessment of Motor Function (Hand)

33. Pain : N ormal Touch : Normal Temperature : Normal Vibration : Normal Joint Position Sense : Normal Two Point Discrimination : Normal Point Localization : Normal Examination of Sensory System:

34. Locomotor System G ait : Normal Upper limbs ( A rms) All the joints of upper limb s are normal. On right side, Wasting of forearm & hand; thumb is adducted and flexed; ulnar clawing present. No visible swelling No tenderness present over joint line Range of motion: Normal

35. Lower Limbs ( L egs ) All the joints of Lower limbs are normal. No visible swelling, deformity or wasting No tenderness present over joint line Range of motion: Normal Locomotor System (contd.)

36. S pine Look: Cervical lordosis : Normal Lumber lordosis : Normal No visible swelling, gibbus or deformity Feel : Tenderness : Absent Local temperature : Normal Step sign : Negative Move: Normal Locomotor System (contd.)

37. Respiratory System Alimentary System Cardiovascular system Genitourinary system Examination of these systems revealed no apparent abnormality Examination of Other Systems:

38. Functional Examination: Ambulation No difficulties Transfer No difficulties Dressing Skill Can put on and take off clothes but difficulty in buttoning, unbuttoning, lacing shoes Eating Skill No difficulties Personal Hygiene No difficulties Communication No difficulties

39. Mr. Saddam Hossain, 27 years, unmarried male, muslim , service holder, normotensive , non-diabetic, non - asthmatic hailing from Chattogram presented with weakness and wasting of right upper limb for last 10 months which is gradual in onset, slowly progressing over time, not associated with any pain or numbness. Salient Features

40. He has history of fall on ground with outstretched right hand prior to onset of this problem. He also complained clumsiness of same hand for last 3 years which occurred after using computer mouse for short period of time . He has no neck pain, fever, night sweats, weight loss or any problem in other limbs. Salient Features (contd.)

41. On examination, Patient is anxious with stable vital signs. His right forearm, thenar & hypothenar muscles are wasted with dorsal guttering and ulnar clawing. Right thumb is adducted and flexed. Wrist & finger extension is 4/5, Finger abduction & adduction is 3/5, Thumb abduction & Extension is 0/5 on right Salient Features (contd.)

42. side with normal muscle tone . Ceiling test, Card test & Scissor test is positive. Deep tendon reflexes are normal with negative Hoffman’s reflex. There is no sensory abnormality. Examination of other limbs, spine and other systemic examinations reveals no abnormality. Due to his conditions, buttoning-unbuttoning of shirt, lacing shoes, lifting & carrying weights are difficult for him. Salient Features (contd.)

43. ? PROVISIONAL DIAGNOSIS

44. Provisional diagnosis Monomelic Amyotrophy

45. Differential diagnosis Brachial Plexopathy Intracranial Space Occupying Lesion Cervical Cord Compression

46. Investigations: CBC , ESR RBS CPK CXR PA view X-ray Cervical Spine both view NCS & EMG of Right Upper Limb MRI of Brachial Plexus

47. Confirmatory Diagnosis

48. Management Objectives : To improve muscle strength To improve hand functions To prevent hand deformity To improve quality of life

49. Non-Pharmacological Pharmacological Management ( contd. )

50. Non-Pharmacological Patient education Physical Therapy & Exercises Occupational Therapy

51. Patient Education Nature of the disease Prognosis Treatment options Importance of exercises

52. Exercises Stretching & Strengthening Exercises Intrinsic hand muscle exercises

53. Occupational Therapy

54. Pharmacological Management Tab. Vitamin B1 , B6 , B12 Cap. Pregabalin

55. Future Plan To treat underlying cause Orthotics