CNS case presentation for medicine postgraduates

CNS case presentation for medicine postgraduates

1. CNS CASE PRESENTATION Dr hv Srinivas

2. NAME : Prakash Chandra AGE : 57 yrs GENDER : male Occupation : grocery store owner HANDEDNESS : Right EDUCATION : primary school ADDRESS : orissa

3. HISTORY OF PRESENTING ILLNESS Nov 2023: The patient was apparently alright, then he started developing pain in both calf muscles, insidious in onset, gradually progressive, more during night time a/w cramps. The patient got symptomatic treatment in the local hospital with painkillers.

4. Dec 2023 : The patient started noticing walking difficulty in both limbs, which was insidious in onset, gradually progressive with no aggravating and relieving factors. He describes it as his left leg toe touches the ground first followed by the heel when he walks. The patient was able to keep his right leg normally. He also noticed difficulty in gripping the footwear with his left leg more then right leg, but he was aware of slipping of footwear. He gives history of lower back ache with no diurnal variation and no radiation to the leg.

5. Jan 2024 Patient gives h/o difficulty in getting up from the floor. Patient gives h/o tingling sensation in both lower limb ,insidious in onset , gradually progressive , initially started at big toe and other fingers progressed till mid ankle. h/o urinary disturbance in the form of increased frequency at night with no hesitancy or urgency.

6. No h/o twitching of muscles, no h/o sensory and motor symptoms in upper limbs. no h/o fever and rashes ,joint pain No h/o cranial nerve involvement No h/o incoordination No h/o trauma No h/o weight loss no h/o feeling band like sensation over the abdomen No h/o difficulty in turning side to side in the bed & getting up from supine position

7. PAST HISTORY NO HISTORY OF SIMILAR COMPLAINTS IN THE PAST . Type 2 dm since 4 years on OHA , (uncontrolled) FAMILY H/O : not contributory

8. PERSONAL HISTORY Diet : mixed Appetite : good Sleep : undisturbed Bowel : normal Bladder : increase frequency Chronic smoker since 20 years, ethanol consumption 60 ml daily for 20 years

9. SUMMARY 57 year old male diabetic , h/o chronic smoking and ethanol consumption came with asymmetrical onset of walking difficulty ( L>R) S/O distal lower limb weakness ( L>R) ,f/b proximal lower limb weakness with sensory involvement in lower limb ( L>R) with increased urinary frequency without upper limb involvement

10. GENERAL PHYSICAL EXAMINATION The patient is conscious, oriented & cooperative. Height – 162 cm Weight – 64 kg Pulse – 88 regular normal volume, character, condition, no radio radial or radio femoral delay. All Peripheral pulses felt BP – 120/70 mm Hg on right arm in sitting position RR- 16 cpm thoraco-abdominal type No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema . No raised JVP No neurocutaneous markers.

11. SYSTEMIC EXAMINATION Central nervous system- Higher mental functions Patient is conscious, oriented to time place and person. Registration –normal Attention and calculation- normal Recall – normal Language naming ,repetition – Normal 3 step command – normal Reading –normal Writing – normal Copying - normal Speech –spontaneous with intact comprehension,fluency . Memory – immediate,recent ,remote –normal.

12. CRANIAL NERVE EXAMINATION CRANIAL NERVES RIGHT LEFT Olfactory N N Optic Visual acuity N N Field of vision, colour vision N N Fundoscopy Occulomotor , trochlear, abducent Pupils Direct & indirect light reflex Accommodation reflex EOM Nystagmus 3mm regular Present N N Absent 3mm regular Present N N Absent

13. Cranial nerves Right Left Trigeminal nerve N N Facial nerve N N Vestibulocochlear nerve N N Glossopharyngeal nerve N N Vagus nerve N N Spinal accessory nerve N N Hypoglossal nerve N N

14. MOTOR SYSTEM

15. NUTRITION MUSCLE BULK RIGHT LEFT ARM 32 32 FOREARM 25 25 THIGH 42 40 LEG 27 27

16. TONE RIGHT LEFT UPPER LIMB – ELBOW WRIST normal normal LOWER LIMB- KNEE ANKLE normal normal

17. POWER RIGHT LEFT SHOULDER 5/5 5/5 FLEXION 5/5 5/5 EXTENSION 5/5 5/5 ADDUCTION 5/5 5/5 ABDUCTION 5/5 5/5 EXTERNAL ROTATION 5/5 5/5 INTERNAL ROTATION 5/5 5/5 ELBOW 5/5 5/5 FLEXION 5/5 5/5 EXTENSION 5/5 5/5 WRIST 5/5 5/5 FLEXION 5/5 5/5 EXTENSION 5/5 5/5 ULNAR DEVIATION 5/5 5/5 RADIAL DEVIATION 5/5 5/5

18. POWER RIGHT LEFT HAND GRIP weak Weak HIP JOINT 5/5 5/5 FLEXION 5/5 5/5 EXTENSION 5/5 5/5 ADDUCTION 5/5 5/5 ABDUCTION 5/5 5/5 EXTERNAL ROTATION 5/5 5/5 INTERNAL ROTATION 5/5 5/5 KNEE JOINT FLEXION 5/5 5/5 EXTENSION 5/5 5/5 ANKLE JOINT DORSIFLEXION 5/5 1/5 PLANTAR LEXION 5/5 5/5 SUBTALAR JOINT INVERSION EVERSION 5/5 5/5 2/5 5/5

19. DEEP TENDON REFLEXES RIGHT LEFT BICEPS 3+ 3+ TICEPS 3+ 3+ SUPINATOR 3+ 3+ KNEE 2+ 2+ ANKLES 2+ 2+

20. SUPERFICIAL REFLEXES RIGHT LEFT CORNEAL PRESENT PRESENT CONJUNCTIVAL PRESENT PRESENT ABDOMINAL-UPPER MIDDLE LOWER PRESENT PRESENT PRESENT PRESENT PRESENT PRESENT PLANTAR FLEXOR EXTENSOR ANAL REFLEX NOT DONE NOT DONE

21. COORDINATION UPPER LIMBS: NORMAL ON BOTH SIDES LOWER LIMBS : NORMAL NO CEREBELLAR SIGNS GAIT-LEFT FOOT DRAGGING

22. SENSORY SYSTEM SUPERFICIAL SENSATIONS FINE TOUCH- DECREASED (20 %) ON LEFT ON LEFT DORSUM OF FOOT . ALL OTHER AREAS NORMAL. PIN PRICK SENSATION-DECREASED (20%) ON LEFT DORSUM OF FOOT..ALL OTHER AREAS NORMAL. JOINT POSITION SENSE- INTACT DEEP SENSATIONS PAIN- DECREASED( 20%) ON LEFT DORSUM OF FOOT ,TEMPERATURE- DECREASED 20%– ON LEFT ON LEFT DORSUM OF FOOT

23. No signs of meningeal irritation. OTHER SYSTEM EXAMINATION- CVS- S1S2 HEARD ,no murmur RS- B/L NVBS HEARD PER ABDOMEN- SOFT NON TENDER

24. DIAGNOSIS NEURODEFICIT-LEFT FOOT DROP(LMN) , BILATERAL SENSORY DEFICIT L/L (L>R), LOWER LIMB WEAKNESS( DISTAL>PROXIMAL , LEFT>RIGHT),WITH UL HYPER REFLEXIA(UMN) LOCALIZATION- L5-S1( RADICLE /PLEXUS ), AHC, LARGE FIBRE SENSORY N PATHOLOGICAL-COMPRESSIVE / INFLAMMATORY/NON INFLAMMATORY ETIOLOGY-DIABETES , ALS ?