72 year old male with B/L Lower Limb weakness

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Patient came with c/o weakness of B/L lower limbs since 5 years 

HOPI : 

Patient was apparently asymptomatic 5 yrs back then he developed tingling sensation of B/L lower limbs.

After that he had B/L lower limb weakness insidious in onset , gradually progressive.

He has tingling sensation of B/L foot , he is able to wear slippers initially, but since 2 yrs he is unable to wear slippers. Not able to squat and stand from squatting position , but able to squat with support.

Able to comb hair , brush teeth , no diurnal variation. Not able to walk without support.

3 years ago he developed Chest pain which is dragging type of pain ,radiating to left hand for which he was operated and Stent was placed.From then he didn’t developed any chest pain

No h/o fever , cough , cold.

No h/o SOB , chest pain , bowel & bladder irregularities.

PAST HISTORY:

K/c/o HTN since 3yrs 

K/c/o CAD 

K/c/o seizures (1 episode 30yrs back)

N/k/c/o TB , asthma , DM , CVA.

Personal History:

He is a farmer.He wakes up at  5 AM and he gathers equipment for work (farming) till 6:30 AM.He has his breakfast around 8 AM and he goes for work and has his lunch     at 1 PM and come back to his home by 4 PM.Drinks tea and has his Dinner at 8 PM .

Diet: Mixed

Appetite: Normal

Sleep:adequate 

Bowel and bladder: Normal

No addictions:

GENERAL EXAMINATION-

Patient is conscious coherent and co operative well oriented to time place and person.

Pallor-Absent 

Icterus - Absent

Clubbing- Absent

Cyanosis- Absent

Lymphadenopathy- Absent

Edema - absent 

VITALS-

Temperature afebrile

Pulse rate 68beats per minute

Blood pressure 110/70mm of Hg

Spo2-97%

Respiratory rate 18cycle per minute

CNS Examination:

Higher mental functions:

Patient is conscious oriented to time place and person 

Speech and language :Normal

Memory :intact( Recent,Immediate,Remote)

Hallucinations -absent

Cranial Nerves:

CN -1:

Sence of Smell - Normal 

CN-2: Normal

CN-3:                                Right                Left

i)EOM movement -          Full                     Full

ii)Direct Light Reflex-      present.           present

iii) Consensual Light Reflex present       Present 

iv) Accommodation Reflex   present      present

v)Ptosis                              Absent            absent 

CN 5:

Sensory over face & buccal mucosa - Normal on both sides

Motor - masseter, Temporalis:Normal

Reflexes - Corneal,Conjunctival Normal.

CN-7

No Deviation of Mouth

Motor:

Nasolabial fold -present on  both sides

Occipito frontalis - Good

Buccinator - Good.

Sensory: Normal

CN-8:

Rinne test positive in both ears

Weber test centralised 

CN-9 and 10 :Uvula,palatal arches movements -Normal 

Gag reflex - N

CN-11:intact

CN-12:intact

Motor System:

Bulk:

Upper limbs:Normal

Lower Limbs:Normal

Tone:

Upper limbs:Normal

Lower Limbs:Normal

Power:                                         Right.                   left

UPPER LIMB MUSCLES:

DELTOID:                                      5/5                     5/5

SUPRASPINATOUS                      5/5                     5/5

INFRASPINATOUS                       5/5                     5/5

RHOMBOID:                                  5/5.                    5/5

SERRATOUS ANTERIOR :           5/5                    5/5

PECTORALIS MAJOR:                 5/5                   5/5

LATISSMUS DORSI :                    5/5.                  5/5

BICEPS:                                          5/5                   5/5

BRACHIORADIALIS:                   5/5                   5/5

TRICEPS:                                      5/5.                   5/5

EXTENSOR CARPI RADIALIS   5/5                  5/5

EXTENSOR CARPI ULNARIS:     5/5                5/5

EXTENSOR DIGITORIUM :          5/5                5/5

FLEXOR CARPI RADIALIS:         5/5                5/5

FLEXOR CARPI ULNARIS:           5/5.               5/5

ABD POLLICUS LONGUS:            5/5                5/5

EXTENSOR POLLICUS BREVIS: 5/5                5/5

EXTENSOR POLLICUS LONGUS:5/5              5/5

FLEXOR POLLICUS LONGUS :     5/5              5/5

ADDUCTOR POLLICIS:                  5/5             5/5

LUMBRICALS INTEROSSEI :         2/5            3/5

FIRST DORSAL INTEROSSEI :       3/5             4/5

FIRST PALMER INTEROSSEI :       3/5            4/5

FLEXOR DIGITORUM PROFUNDUS :5/5      5/5

ABDUCTOR DIGIT MINIMI :             4/5         4/5

LOWER LIMBS:

ILIO PSOAS                                          5/5         5/5

ADDUCTOR FEMORIS :                    4/5          5/5

GLUTEUS MEDIUS AND MINIMUS :  5/5.    5/5

GLUTEUS MAXIMUS                         5/5.       4/5 

HAMSTRING.                                      4/5         5/5

QUADRICEPS.                                      5/5        5/5

TIBIALIS ANTICUS                              2/5        3/5

TIBIALIS POSTICUS                          2/5           2/5

PERONEI.                                             2/5           2/5

GASTROCNEMIUS                           2/5             2/5

EXTENSOR DIGITORUM                1/5              2/5

FLEXOR DIGITORUM                     1/5               1/5

EXTENSOR HALLUCIS LONGUS 1/5.               1/5 

EXTENSOR DIGITORUM BREVIS 1/5            1/5

Reflexes:          Right           Left

Biceps:               1+                1+

Triceps:              1+                 1+

Supinator:          1+                    1+

Knee:                Absent         absent 

Ankle:                Absent        absent

Planter:              Mute           Mute

Sensory system:

                               Right.                 Left 

Crude touch :    

Upper Limb            Present.             present

Lower Limb           Present               Present 

Pain :

Upper Limb            Present.             present

Lower Limb           Present               Present 

Fine touch:

Upper Limb            Present.             present

Lower Limb           Present               Present 

Vibration: 

Upper limb:              Right.                    Left

1) Styloid:      Present(6.7 sec)         present(6.9 sec)

2)olecranon process:present (7.3 sec) present (7.1 sec)

3)Acromion process:present(10.2 sec) present(9.6 sec)

Lower Limb :

1) Tibial tuberosity : can’t sense vibration 

2)Shaft of Tibia:can’t sense vibration 

3)Medial Malleolus:can’t sense vibration 

Position sense:      

                                   Right             Left

Upper Limb              10/10           10/10

Lower Limb              5/10              4/10

-Graphaesthesia-Postive

-Stereognosis-Positive

Cerebellar signs:

-Titubation:absent

-Nystagmus:absent

-Dysarthria:absent

-Hypotonia:absent

-Intention tremor:absent

-Coordination

a.Finger Nose test: Normal 

b.Heel Knee test:Impaired 

https://youtube.com/shorts/-9kncoerI3Q?si=vtaHUPhy-PYlcP6P

https://youtube.com/shorts/bcIdrmLAJv4?si=XSwvCPJ9vJl3YRX7

c. Dysdiadokokinesia: Negative( able to perform rapid alternative movements)

https://youtube.com/shorts/oZsLJ_k15SM?si=uxxHvIufBRbspvNa

Gait:

https://youtube.com/shorts/pYsECZ1nC4o?si=dSYaE45kNbCwN-0s

https://youtube.com/shorts/c5Wb6ilDKVo?si=Lj5rjuhYK_uO9mcS

Signs of Meningeal Irritation:

Neck stiffness: absent 

Kernig’s sign :absent

Brudzinski’s sign:absent

PER ABDOMEN-

Soft,non tender,Distended

No organomegaly

CVS:

S1 S2 heard , No murmurs

RS:

BAE present,Normal Vesicular Breath Sounds present.

Investigations:

NCS shows reduced motor conduction velocity in Right median nervewith conduction Block and reduced motor conduction velocity in left mediam Newe. There is conduction block across right ulnar nerve.Absent MUAPS  in Bilateral peroneal nerve and reduced CMAP in B/L TibialNerves . sensory conductions show absent SNAP in Right median nerve with absent SNAP in Bilateral sural nerves.

Features S/o sensory motor Demyelinating Neuropathy with conduction Block.

25/08/23

Haemoglobin:13.1g%

Red blood cells:4.38million/mm3

Pcv:32.7%

Platelet count:2.04lakhs/mm3

Total leucocyte count:8,700/mm3

25/08/23

Blood urea 32mg/dl

Sr creatinine 1.0mg/dl

serum Na 145mmol/dl

Serum K 4.4mmol/dl

Serum Cl 102mmol/dl

25/08/23

Total bilirubin:o.87mg/dl

Direct bilirubin: 0.19mg/dl

Indirect bilirubin:1.5mg/dl

Alkaline phosphatase:168 IU/L

SGPT:21 IU/L

SGOT:15 IU/L

Protein total: 6.9G/DL

Albumin:4.12g/dl

Albumin and globulin ratio:1.4

MRI LUMBOSACRAL SACRAL SPINE WITH WHOLE SPINE SCREENING -IMPRESSION IS DIFFUSE SMOOTH THICKENING OF CAUDA EQUINA ROOTS ,LUMBOSACRAL PLEXUS AND PROXIMAL PORTIONS OF SCIATIC NERVE WITH NO ENHANCEMENT ON POST CONTRAST IMAGES

Treatment:

1)INJ METHYL PREDNISOLONE 1000MG IV/OD IN 100 ML NS OVER 1 HR

 2) INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD

3)TAB CLOPIDOGREL +ROSAVASTATIN (75/10) PO/HS 

4) TAB TELMA 40 MG PO/OD