A 65 year old male with weakness in both his lower limbs since 15 days.

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possible differential diagnoses on presenting problems

1. Paroxysmal nocturnal dyspnea
  • (1) increased ventilatory demand such as with exertion, febrile illness, hypoxic state, severe anemia, or metabolic acidosis;
  • (2) decreased ventilatory capacity such as with pleural effusion, intrathoracic mass, rib injury, or muscle weakness;
  • (3) increased airway resistance such as with asthma or chronic obstructive pulmonary disease; and
  • (4) decreased pulmonary compliance such as with interstitial fibrosis or pulmonary edema.

  • puslus bisferans and Duroziez's sign positive indicates aortic stenosis or regurgitation

2. Weakness of lower limbs
  • proximal muscle myopathy effecting lower limbs
  • on  examination he had babinski positive and absent knee and ankle jerk indicate a lesion of chord compression in lumbar spine.
3. Prostate malignancy as DRE showed flat non nodular prostate

More information about history and examination to reach the final diagnosis

JVP to assess right heart function,
upper limb reflexes to assess cervical spinal chord
symptoms of lower urinary tract obstruction
  • hesitancy (worsened if the bladder is very full);
  • poor flow (unimproved by straining);
  • intermittent stream – stops and starts;
  • dribbling (including after micturition);
  • sensation of poor bladder emptying; episodes of near retention.

Investigation
  1. Echocardiogram to assess heart functioning and anatomy
  2. MRI SPINE to locatise area of chord compression and
  3. Per rectal or abdominal ultrasound scan of prostate to identify prostate lesion
  4. Serum prostate specefic antigen as screening for prostate lesion
  5. Serum creatinine, electrolytes and haemoglobin should be measured.
Diagnosis

2D echo showed
  • EF IS 55 % 
  • Dilated IVC OF 1.9CM,
  • Dilated RA
  • RSVP-38MMHG
  • Mild TR with mild PAH, Trivial AR 
  • Good LV systolic function, 
  • No RWMA Diastolic Dysfunction
right ventricular systolic pressure is 38 indicates mild pulmonary artery hypertension
and tricuspid regurgitation

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