CLINICAL CASE

DISCUSSION- NEUROLOGY
PATIENT DETAILS
Name Mr X

Age 40 y

Sex Gentleman

Occupation Shopkeeper

Resident of Bulandshahar, UP

Education Secondary

Handedness Right
 CHIEF COMPLAINTS

No prior comorbidities

He presented to AIIMS Neurology OPD with complaint of:

Progressive weakness of bilateral lower limbs for 15 days
HOPI
Apparently well 15 days ago

Started having difficulty in getting up from the toilet seat, had to take support of the sink

The amount of support increased gradually – initially one hand then two hands over a period of 10 days.
Since the last 5 days he is unable to get up from bed without support. He is unable to turn side to side in
bed for the same duration. He required the support of two people to walk and help him get up from bed

No H/O slippage of slippers from feet and difficulty in gripping slippers, difficulty buttoning, eating food
with a spoon, combing hairs or bathing by himself.

No history of twisting of legs while walking, spasmodic contractions in lower limbs while walking,
stiffness in lower limbs

No history of thinning of bilateral lower limbs, or visible muscle contraptions at rest. No H/O diurnal
variation in weakness
 HOPI

No history of loss of sensation of smell, diminituion of vison, double vison,

decreased sensations over face, difficulty in chewing food, deviation of angle of
mouth, decreased hearing, regurgitation of food, visible tongue pulsations, of
deviation of neck to one side

Patient is able to feel his clothing, feel hot and cold water while bathing, no
history of deformation of toes or any ankle joint swelling or any numbness. No
history of any tingling and parathesis

No history of bowel bladder dysfunction, dizziness on standing, loss of early

morning erections, any abnormal sweating
 HOPI

No H/O any involuntary movements or twitching

No h/o resting tremors

No h/o behavioural changes

No h/o involuntary movement of body parts

No h/o falls
No h/o difficulty in comprehension
NEGATIVE HISTORY
 PAST HISTORY

Had one episode of hospitalisation one month ago for a febrile illness with
jaundice. Received IV medications there, nature of which in unknown and was
discharged in 5 days.

No hospitalisation or surgical intervention in the past

No H/S/O DM, HTN, thyroid dysfunction, epilepsy

 FAMILY HISTORY

No similar complaints in the family or neighbours

No history of any genetic disease in the family

No history of early sibling deaths among cousins

 PERSONAL HISTORY

Married

Chronic alcoholic for past 7 years, taking 40gm of alcohol daily

Mixed diet

Normal Bowel habits

Normal 7-8h sleep

No overcrowding at home (4 members in 2 rooms)

Lives in a pucca house, with no factories nearby

 TREATMENT HISTORY

No intake of any alternate medicines before or after the onset of symptoms

 SUMMARIZE

40 year old gentleman, with a history of febrile episode one month ago currently
presenting with bilateral symmetrical progressive LMN type of weakness in bilateral
lower limbs without any sensory, bowel bladder, cranial nerve or cerebellar
involvement, showing no obvious diurnal variation
 GENERAL PHYSICAL EXAMINATION

Conscious, cooperative, oriented to time, place and person

Average built with good nutrition with Wt 76 kg, Ht 168 cm (BMI 26.9 kg/m2)

Temperature of 98.7 °F

RR – 16 /min

Pulse – 86/min, regular, normal volume and character, no R-R/R-F delay

BP in supine position: Rt arm- 120/76 mm Hg, Lt arm- 126/80 mm Hg

JVP was normal

SpO2 99% RA

No IV lines or catheters in place

No pallor, icterus, cyanosis, clubbing, lymphadenopathy or edema

Hair, skin and nails were normal

Good oral hygiene

Facies normal

No frontal balding

Slightly protruding abdomen

Which system do you wish to examine?

From where do you start your examination?

 HIGHER MENTAL FUNCTIONS

Oriented to time, place and person

MMSE- 28/30
 CRANIAL NERVES
I- Normal sense of smell B/L

II- VA 6/6 both eyes, normal colour vision and visual field, fundus showed mild temporal disc pallor B/L
(image NA), pupils NSNR with no RAPD

III, IV, VI- Broken pursuit movements. (N) conjugate movements, normal saccades movements, no
nystagmus, normal size of palpebral fissure, normal light and accommodation reflex

V- Sensory and motor exam (N), jaw jerk absent

VIII- Normal hearing, AC>BC, Weber’s not lateralised to one side

IX, X- Symmetric palatal arches, uvula midline on phonation, gag reflex normal

XI- No SCM/trapezius weakness

XII- No deviation of tongue, no decrease in power

 MOTOR EXAMINATION

Inspection:

Patient was examined in supine position, both lower limbs were extended and
externally rotated

No visible wasting of muscles in lower limbs.

No visible fasciculations.

No trophic changes in bilateral lower limbs

MOTOR

Motor examination:

Bulk:

Tone:
 POWER
RIGHT LEFT

Shoulder
Abduction/Adduction 2/5 2/5
Flexion/Extension 2/5 2/5
Elbow
Flexion 3/5 3/5
Extension 2/5 2/5
Wrist
Flexion/Extension 4-/5 4-/5
Hip
Flexion/Extension 2/5 2/5
Abduction/Adduction 2/5 2/5
Knee
Flexion/Extension 2/5 2/5

Ankle
Flexion/Extension 4+/5 4+/5
Hand Grip 80% 80%
 NEUROLOGIC EXAMINATION
Reflexes:
Superficial: Deep Tendon Reflexes
B/L plantar flexor
Superficial abdominal reflex present Reflex Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee 2+ 2+
Ankle Absent Absent
 SENSORY

Sensory Examination Right Left

Light touch Upper limb Normal Normal

Lower limb Normal Normal
Vibration Upper limb Normal Normal
Lower limb Normal Normal
Joint position Upper limb Normal Normal

Lower limb Normal Normal

 SENSORY

Sensory Examination Right Left

Pain Upper limb Normal Normal

Lower limb Normal Normal

Temperature Upper limb Normal Normal

Lower limb Normal Normal

CEREBELLAR

Coordination
 Could not be performed

Normal speech, no scanning.

Gait: could not be assesed
 NEUROLOGICAL EXAMINATION

SUMMARY
LOCALISATION
DIFFERENTIALS