57 year old male with lower limb weakness
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Case :
A 57 year old male autodriver by occupation came to the opd with a complaint of difficulty in walking since 7 days
Giddiness since 7 days
History of presenting illness.
Patient was apparently asymptotic 2 months back and later developed pain in the lower limbs .from last 7 days the patient doesn't able to walk having weakness in the lower limbs and swaying towards right side which was incidouus in onset . there is no diurnal variation in weakness of the limbs
He is an auto driver by occupation he developed pain in lower limbs , for which he has visited a local RMP and given a medication ( unknown)
The next day he developed excessive sweating and associated with vomiting which was non projectile non bilious and watery ( 2- 3 episodes), giddiness , weakness of lower limbs and swaying to right , he visited a local hospital CT was done and medication was given and referred to our hospital on day of admission in evening he perceived the objects as two ( diplopia) which resolved spontaneously after 30 min.
There is a history of fever nearly 1 month back which was diagnosed as typhoid and medication was given
No h/o trauma
He was diagnosed with HTN 1 year back which was incidental finding he took medication for 3 months after that as the HTN was normal he stopped taking medication until now
Past history
there is no history of similar complaints in the past
HTN : since 1 year
Not a case of diabetes , asthma , copd , TB , epilepsy
H/ o typhoid fever 1 month back
Personal history
Marital status : married
Diet : mixed
Appetite : normal
Bowel and bladder: he has constipation (once in 2 days ) bladder movements are regular
Sleep : adequate
Addictions :
A chronic alcohol for 20 years and stopped 2 years back
And a chronic smoker for 22 yrs consumed in form of beedi.
General physical examination
Patient was concious coherent cooperative moderately built and nourished , well oriented to time place and person
Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : present
Lymphadenopathy : absent
Edema : absent
Vitals
Temperature : 98.6° F (afebrile)
PR : 86 bpm
BP : 180 / 100 ( 5/09/2022 , 5pm)
RR : 18 cpm
Clubbing
Systemic examination
CNS :
HIGHER MENTAL FUNCTIONS:
Oriented to time place and person
Immediate memory:Intact
Short term memory:Intact
Longterm memory:Intact
No delusions and hallucinations.
CRANIAL NERVES:
Olfactory nerve(I): Smell is intact
Optic nerve(II):size of both pupils equal.
Pupil reactivity to light:present
Direct and indirect light reflex are present in both eyes.
Oculomotor(III),Trochlear(IV)and Abducens(VI):ocular movements present.Brief period of diplopia,No ptosis,Horizontal Nystagmus Present
Trigeminal(V): Sensations over the face present.
Corneal reflex:present
Jaw jerk: Absent.
Muscles of mastication:Normal(No wasting)
Facial nerve(VII): No deviation of mouth
The wrinkles on both sides of forehead are present.
Taste:intact.
Secretions:Normal in eyes.
Vestibulocochlear nerve(VIII):Hearing intact.
No positional vertigo and nystagmus.
Glossipharyngeal (IX) and Vagus(X): uvula is centre and pilatoglossus pillars are normal and gag reflex intact.
Taste sensations from posterior tongue is normal.
Spinal accesory(XI):Trapezius and Sternocleidomastoid normal.
Hypoglossal(XII): Tongue (opening )central in postion.
No weakness and wasting of tongue.
Tongue moments normal.
MOTOR SYSTEM:
No visible muscle wasting is seen on inspection.
TONE OF THE MUSCLE:
Right: upper limb—Normal tone
lower limb—Normal tone
Left:Upper limb—-Normal tone
lower limb—-Norma tone.
POWER OF MUSCLE:
Right upper limb: 5/5
(Tested for supraspinatus,Deltoid,infraspinatus,Rhomboid,pectoralis major,latissimus dorsi,biceps, brachioradialus, triceps,Extensor carpi radialis, Extensor carpi ulnaris,Extensor digitorum,Flexor carpi radialis and Flexor carpi ulnaris,Abductor pollicis longus, Extensor pollicis brevis,Extensor pollicis longus,Lumbricals,Abductor digiti minimi.)
Right lower limb:5/5
(Tested for Quadriceps femoris,Tibialis anterior,Tibialis posterior,Gastrocnemius,peronei,Extensor digitorum longus,flexor digitorum longus,extensor digitorum brevis,extensor hallucis longus)
Left upper limb:5/5
Left lower limb:5/5
POSTURE AND GAIT:
Broad based gait
No involuntary movements or tremors are seen.
SENSORY SYSTEM:
Fine touch, crude touch and pain intact in all the four limbs.
Temperature: Differentiation between cold and hot objects present.
Joint position:5/10 (incorrect)in Right lowerlimb and 5/10 (incorrect)in left lower limb.
No abnormal sensations are present
REFLEXES:
Tendon reflexes:
Jaw jerk: Not seen
Right:
Biceps jerk:+++
Triceps jerk:+++
Supinator jerk:+++
Knee jerk:+++
Ankle jerk:+++
Left side:
Biceps jerk:+++
Supinator jerk:+++
Triceps jerk:+++
Knee jerk:+++
Ankle jerk:+++
Superficial reflex:
Abdominal reflex: present
Cerebellar function tests:
Titubation absent
Trunkal ataxia/gait ataxia swaying towards right
No dysarthria,tremors,hypotonia
Coordination tests:
Finger nose test: done by both hands(normal).
No overshooting.
Finger to finger testing:no incordination.
Diadokokinesia: normal with right hand.
Heel knee test: no incordination
Rhombergs test: swaying towards right with eyes open
Steriognosis : intact
Autonomic nervous system:
Increased sweating +
No postural hypotension
Meningeal signs:
No neck pain
No spinal and cranial abnormalities
No carotid bruit
CVS :
Respiratory system:
On inspection :
Shape :
trachea central , bilateral air entry present , symmetrical expansion of chest present , no scars and sinuses
P/abdomen :
On inspection : abdomen was (slightly distended )
No visible scars and sinuses
Umbilicus : central and normal
On palpation : soft and non tender
On percussion
On auscultation : bowel sounds were heard
Investigations
ECG
MRI brain
CVA ? PCA stroke
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