CASE PRESENTATION

CHAIR-PERSON: DR SANTANU BHAKTA

PRESENTER: DR. MADHURIMA ROY
MY PATIENT:

 NIKHIL KUMAR DAS

 74YRS
 HINDU
 MALE
 ADDRESS:
 MARINE ENGINEER
 DATE OF ADMISSION:15.02.24
 DATE OF EXAMINATION:18.02.24
 CHIEF COMPLAINTS

PROGRESSIVE WEAKNESS OF BOTH

LOWER LIMBS 2 YEAR

DIFFICULTY IN SWALLOWING
HISTORY OF PRESENT ILLNESS
LOWER LIMB WEAKNESS
 Insidious onset

 Gradually progressive

 Slipping of footwear, frequent ankle tripping. Difficulty in lifting foot off the ground
and shuffles forward.

 Later progressed→ difficulty in getting up from seated/ squatting→ turning in bed.

 Associated with stiffness of lower limbs

 No significant thinning of limbs

 No h/s/o abnormal twitching movements over his limbs or body

 Ocasionally complains of sudden painful contractions of lower limbs

 UL- no worsening from prior status

DIFFICULTY IN SWALLOWING

 GRADUALLY PROGRESSIVE

 MORE TO LIQUIDS THAN SOLIDS

 FREQUENT CHOKING WHILE ATTEMPTING TO DRINK

 NO DIFFICULTY IN CHEWING OR MIXING OF FOOD

 NO H/O NASAL REGURGITATION OF FLUIDS

RECURRENT FALLS…
 Multiple episodes since last few years

 Mostly without any loc/ altered sensorium. Occurred due to ankle tripping or
while getting up. Not in any particular direction.

 Some episodes→ associated with transient altered sensorium for ~1-2 minutes

 Not associated with any jerky movements, tongue bite or involuntary passage
of urine during these episodes

 Regains consciousness without any significant post event confusion

 One episode associated with prolonged unconsciousness with head injury

which required repair with sutures in 2019 which was probably d/t ankle tripping

 Few days back-

BLADDER AND BOWEL

 Since 2005; however worsened over the last 2 years

 Urgency

 Increased frequency

 Occasional urge incontinence

 Intermittency, hesitancy

 At present he has been catheterized after hospital admission

 BOWEL- c/o constipation. Has been admitted a number to times to relieve it.
IN SLEEP….

 Abnormal movements as reported by care giver

 Especially towards the later part of the sleep

 Seems as if he is enacting out dreams

 Patient himself cannot recall any of these

 Care giver c/o snoring in sleep

 No h/s/o stridor
SENSORY SYMPTOMS

 Since 2005 and persistent. Not progressive

 H/O burning sensation in both lower limbs and trunk since 2005.

 No definite level could be described

 Transient, Intermittent attacks of sharp, lancinating, electric shock like

sensation starting from lower back and radiating down along legs
NEGATIVE HISTORY

There is no history of:

 Significant cognitive decline, seizures

 Other cranial nerve dysfunction→ loss of smell, disturbance in vision, double

vision, abnormal facial sensation, deviation of mouth, eye opening/
closure, hearing loss, difficulty in speaking etc

 Other Abnormal movements

 No h/o inappropriate laughter or crying

PAST HISTORY

 2005- H/o slippage and fall with trauma to cervical region f/b weakness of all 4
limbs→ gradually recovered with conservative management.

 Had been ambulatory with support and was able to perform ADL with
assistance

 Hospital admissions a number of times→ mostly due to bowel obstruction and

urinary tract infections.

 Hypertensive on medications

 Non diabetic, euthyroid

 No h/s/o stroke
 FAMILY HISTORY: Nothing significant

 PERSONAL HISTORY:
 Married with 2 children; widower
 Diet: mixed Indian diet
 Addiction: reformed smoker. Used to smoke > 10/ day for 30 yrs. Abstinent for last
13 years
 Sleep: normal except for the RBD
 Apetite: reduced
 Bladder & bowel: already described
 No h/s/o/ high risk behavior

 TREATMENT HISTORY: Was being evaluated outside prior to admission in this

institute. Has been on multiple oral medications.
SUMMARY
 74 YR OLD HYPERTENSIVE MALE PATIENT PRESENTED WITH A 2 YEAR HISTORY
OF-

 INSIDIOUS ONSET GRADUALLY PROGRESSIVE SPASTIC PARAPARESIS WITH

PROGRESSIVE GAIT DIFFICULTY
 UPPER MOTOR TYPE DYSPHAGIA
 ASSOCIATED WITH WORSENING FEATURES OF UMN BLADDER SYMPTOMS (WITH
FEATURES S/O DSD)

 WITH FEW SYNCOPAL ATTACKS AND A H/O RBD

 There is a past h/o quadriparesis following cervical trauma in 2005.

ANALYSIS FROM HISTORY

 B/L CORTICOSPINAL TRACTS

ABOVE MEDULLA
 B/L CORTICO BULBAR FIBRES

 BLADDER- BETWEEN PMC AND SACRAL CENTRES

 SYNCOPE- AUTONOMIC CONNECTIONS

 RBD- BRAINSTEM AND CONNECTIONS WITH THE SPINAL CORD

 SENSORY SYMPTOMS- B/L SPINOTHALAMIC TRACT. ?? LEVEL

DIFFERENTIALS

VASCULAR

NPH
RBD??
SYNCOPE??

?? ASSOCIATED
SYNUCLEINOPATHY
EXAMINATION
GENERAL EXAMINATION
 Alert, conscious and cooperative
 Facies- not suggestive of any particular disease. No obvious facial asymmetry
 Decubitus- supine, lower limbs extended and externally rotated
 Built- average
 Nutrition- poor. Pressure sores.

 Pallor
➢ Pulse-
 Cyanosis
absent ➢ Supine BP-
 Jaundice
➢ RESP-
 Clubbing
➢ Temp- not raised
 Oedema- sacral oedema
Contd…

 Neck veins- not engorged

 Neck glands- not enlarged

 General appearance- supine with LL extended and externally rotated at

hip, knees and ankles. UL- inability to extend the fingers; remain flexed at

interphalangeal joints. Foley’s Catheter insitu.iv cannula insitu

CNS EXAMINATION

 HMF- NORMAL

 SPEECH- HYPOPHONIC.

 MENINGEAL SIGNS- ABSENT

 CRANIAL NERVES- JAW JERK-

 GAG REFLEX-
MOTOR SYSTEM

 APPEARANCE-

 BULK: DISUSE ATROPHY-

 MEASUREMENTS:

 NO FASCICULATIONS

 TONE- SPASTICITY IN BOTH LOWER LIMBS. EXTENSOR TONE>> FLEXOR TONE

 UL- COGWHEEL RIGIDITY ACROSS RT WRIST

 POWER-
POWER
RIGHT LEFT

SHOULDER

ABDUCTION 4/5 4/5

ADDUCTION 4/5 4/5

EXTENSION 4/5 4/5

FLEXION 4/5 4/5

INTERNAL ROTATION - -
EXTERNAL ROTATION - -
ELBOW

FLEXION 4+/5 4+/5

EXTENSION 4/5 4/5

 RIGHT LEFT
WRIST
FLEXION 4+/5 4+/5
EXTENSION 4/5 4/5
HAND GRIP poor poor
HIP JT
FLEXION 1/5 0/5
EXTENSION - -
ABDUCTION 2/5 1/5
ADDUCTION 2/5 1/5
EXTERNAL ROTATION - -
INTERNAL ROTATION - -
KNEE JT
FLEXION - -
EXTENSION 1/5 1/5
ANKLE
DORSI FLEXION 1/5 1/5
PLANTAR FLEXION 1/5 1/5
REFLEXES- DEEP TENDON REFLEXES
RIGHT LEFT

BICEPS 2+ 2+

SUPINATOR 2+ 2+

TRICEPS 2+ 2+

KNEE 3+ 3+

ANKLE 4+ 4+

ANKLE CLONUS PRESENT -----------------

SUPERFICIAL REFLEXES

 CORNEAL REFLEX- PRESENT

 ABDOMINAL REFLEX- LOST IN ALL SEGMENTS

 PLANTAR- B/L EXTENSOR

 CREMASTERIC REFLEX- ABSENT

SENSORY SYSTEM

 PAIN
 TEMPERATURE

 JPS
 VIBRATION

 CORTICAL SENSATIONS
 CEREBELLUM- COULD NOT BE TESTED PROPERLY
 EXTRA PYRAMIDAL SYSTEM- NO ABNORMAL MOVEMENTS. RIGIDITY AS
DESCIBED
FINAL DIAGNOSIS

CHRONIC SMALL VESSEL DISEASE

+
IDIOPATHIC PARKINSONISM