57 year old with lower limb weakness

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CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS 

Case

A 57 year old male autodriver by occupation came to the opd with a complaint of inability to stand and walk since 10 days. 

History of presenting illness. 

Patient was apparently asymptomatic 10 days back, later he was unable to walk and was falling down due to the imbalance.

He developed fever 7 days ago which he got treated at clinic in suryapet where they assumed it as typhoid and treated it. He was also diagnosed with hypertension. On mentioning his inability to walk they refered him to a higher institution where he is now.  

Patient was taking small steps with swaying motion and loss of sense of balance. 

History of pain and numbness at soles of feet on walking, loss of balance. 

There is no history of fever, trauma, neck stiffness, nausea, vomiting, vertigo, blurring of vision. 

No history of headache, loss of limb control, sensory symptoms. 

Past history 

Diagnosed as hypertensive one year ago which he took medication for 3 months and stopped. 

No history of diabetes, asthma, TB, epilepsy, CAD

No history of any surgeries 

Personal history

Diet: mixed.           Appetite: normal

Bowel and bladder: regular.      Sleep: adequate 

Addictions: chronic smoker since 22 years. 

                   Chronic alcoholic since 20 years stopped          

                    2 years ago. 
Allergies:

 

Family history: no family members with similar complaints 

Treatment history: took anti hypertensive medication for three months one year ago. 

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 : sent

    Pallor

Clubbing 

                            Palmar creases

           

Vitals 

Temperature : 98.6 F

PR : 86 bpm

BP : 180 / 100 ( 5/09/2022 , 5pm)

RR : 18 cpm

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 : 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

Diagnosis:CVA ? PCA stroke