CASE PRESENTATION

BIODATA
Mr. Raheem, 65 year old, Male, Koyilandy,
Fisherman.

PRESENTING COMPLAINTS
Weakness of both lower limbs – 3days
Weakness of both upper limbs – 1day
HISTORY OF PRESENT ILLNESS

• 3 days back in the evening he felt weakness of

both lower limbs below the knee, but he was
able to walk on his own.

• By next day morning the weakness progressed

to an extent that he sought help from his
grandchildren to walk. He noticed buckling of
knees while he attempted to walk on his own .
• After some time he could not even walk with
support and was unable to move both lower
limbs.

• On the following day he also developed

weakness of both upper limbs and he was
unable to comb his hair.

• He also complaints of paraesthesia below the

knee and on hands.
• No h/o of bowel and bladder involvement

• There was h/o of fever 2 weeks back which

lasted for 2 days and relieved on taking
medication. No h/o rashes, loose stools,
painful urination

• No h/o heat intolerance, nocturnal diarrhoea,

excessive sweating.
• No h/o seizures, LOC or altered sensorium.
• No h/o headache, nausea or vomiting.
• No h/o fall or trauma
• No h/o deviation of angle of mouth, anosmia,
diplopia, blurred vision, hearing loss, tinnitus,
vertigo, dysphagia, nasal regurgitation,
difficulty in speech.
PAST HISTORY
• No history of similar illness in the past.
• Hypertensive for 10yrs on medication.
• He has been admitted 8yrs back for CAD,
which was managed conservatively, details of
which are not known
• No h/o DM , dyslipidemia, pulmonary TB,
bronchial asthma
PERSONAL HISTORY
• Consumes mixed diet.
• Appetite not reduced.
• Catheterised
• Bowel and bladder habits normal.
• Was smoker for 25 yrs, quit smoking 10yrs
back.
• Non alcoholic.
FAMILY HISTORY
No history of similar illness in the family.

SOCIOECONOMIC STATUS
Belongs to a middle class family.
GENERAL EXAMINATION
• He is lying on bed but not able to get up on his
own
• He is catheterised
• Conscious, oriented
• Moderately built and nourished
• No pallor, icterus, cyanosis, clubbing,
lymphadenopathy, oedema
• No thyroid swelling, varicose vein.
VITALS

Pulse-88/min, regular rhythm, normal volume

and character. No vessel wall thickening, no
radio femoral delay. All peripheral pulsations
are felt equally on both sides
BP-130/90mmHg, right arm, supine position

Respiration-21/min, regular rhythm,

abdominothoracic type

Temperature-Afebrile
EXAMINATION OF NERVOUS SYSTEM
Higher functions
• Alert
• Oriented in time, place and person
• Normal immediate, recent and remote
memory
• Right handed person
• Speech normal
• No delusions, hallucinations or emotional
instability
Examination of cranial nerves

CN I – sense of smell normal on both sides

CN II – visual acuity, visual field, colour vision

normal on both sides.

CN III, IV, VI – No ptosis, squint

Pupil normal size and shape
Direct and indirect light reflex present
on both sides
Accommodation reflex present
CN V - Sensations perceived equally on both
sides of face
- Temporalis and masseter equally prominent
on both sides on clenching teeth
- Corneal and conjunctival reflex absent

CN VII - Loss of wrinkling of forehead on both sides

- When the patient tries to close the eyes both the
eyeballs move upwards
- Flattening of nasolabial fold on both sides
- Loss of taste in ant 2/3rd of tongue
CN VIII -Rinne’s positive on both sides
-Weber’s centralised
-Schwabach’s same as that of
examiner’s on both side.
-No tinnitus, auditory hallucination

CN IX, X -Uvula central

-Movement of palate normal
-No nasal regurgitation
-Gag and palatal reflex not tested
CN XI - Shrugging of shoulder present
- Movt of neck against resistance present

CN XII - No deviation of tongue

-No fasciculations, wasting
-Sidewise movt of tongue against
resistance present.
Examination of motor system
Bulk: No muscle wasting, comparable on both
sides
Tone: Hypotonia in upper and lower limbs of
both sides
Power:
Rt Lt

UL proximal ms 3/5 3/5

UL distal ms 4/5 4/5
Lower limb 1/5 1/5
Examination of reflexes
Superficial reflexes
• Corneal reflex – lost on both sides
• Conjunctival reflex – lost on both sides
• Abdominal reflex – Absent
• Plantar reflex – flexor plantar reflex
• Cremastric reflex
• Anal reflex Not tested
• Bulbocavernous reflex
Deep tendon reflexes
• Jaw jerk
• Biceps jerk
• Triceps jerk
• Supinator jerk ABSENT
• Knee jerk
• Ankle jerk

Primitive reflexes – Absent

No involuntary movements
Examination of sensory system
Spinothalamic sensations
• Touch
• Pain Perceived equally on both sides
• Temperature
Posterior column sensations
• Vibration
• Joint sense Perceived equally on both
• Position sense sides
• Deep pain
• Romberg’s sign – Not tested
Cortical sensations
• Tactile localization
• Two point discrimination Normal on both
• Stereognosis sides
• Graphesthesia

No signs of meningeal irritation

Skull and spine – normal
No carotid bruit
No temporal artery tenderness
EXAMINATION OF CARDIOVASCULAR SYSTEM
JVP not elevated.
Apex beat palpable in the left 5th intercostal
space 1cm medial to the midclavicular line.
First and second heart sound heard normally.
No murmurs or additional sounds.
EXAMINATION OF RESPIRATORY SYSTEM
Trachea central
Normal vesicular breath sounds heard normally
on all lung areas
No added sounds

EXAMINATION OF GASTROINTESTINAL SYSTEM

Oral cavity normal
Shape of abdomen normal
No palpable mass
Normal bowel sounds heard
 SUMMARY
• 65 year old male, hypertensive for 10 yrs on
medication, with h/o fever 2 weeks back, now
presented with weakness of upper and lower
limbs of both sides, ascending type,
symmetrical, proximal more than distal.
Paraesthesia of both upper and lower limbs.
O/E:
Hypotonia of B/L upper and lower limbs.
Power:

Absent DTR on both sides

Flexor plantar response on both sides
B/L LMN facial nerve palsy
DIAGNOSIS
Quadriparesis
LMN
Polyradiculoneuropathy
Demyelinating
GBS
Post infectious