Multiple cranial nerve palsy case final.pptx

A case of multiple cranial nerve palsy

1. APPROACH TO MULTIPLE CRANIAL NERVE PALSIES Dr.SURYAPRASANTH.G Final year post graduate Department of general medicine

2. HISTORY A 58 year old female patient resident of Vellore,housewife by occupation belonging to lower socioeconomic class educated upto third standard,right handed person,presented with the chief complaints of Headache * 4 days Double vision * 4 days Drooping of right eyelid *4 days Right sided facial pain * 4 days Decreased sensation of right half of face *4 days

3. HISTORY OF PRESENTING ILLNESS Patient was apparently normal 4 days back.Next day she was awakened at 4.00am in the morning due to sudden onset of headache which was holocranial,throbbing in nature, continuous ,varying in intensity, progressive, associated with right sided eye pain and watering from the right eye No H/o vomiting , giddiness,flashes of light ,hearing abnormal sounds prior to the headache Headache was not associated with fever,loss of consciousness, difficulty or unsteadiness in walking

4. By afternoon the patient developed double vision on looking in all directions more in the right side and for far vision and disappeared on closing one eye.On further questioning the patient said that the images were horizontally separated followed by drooping of Right eyelid It was not associated with diurnal variation Patient also developed episodes of brief , electric shock like sensation over the right half of face aggravated by chewing food/ touch H/o inability to feel hot/cold sensation in the right half of face No H/ o difficulty in chewing food

5. H/ o difficulty in vision both for far and near objects No H/o difficulty in colour vision No H/o loss of smell sensation No H/o facial asymmetry in the form of absence of wrinkling,inability to close the eye No H/o drooling of saliva,dribbling of food Able to hold air in the cheeck No H/o deviation of angle of mouth No H/ o alteration in taste sensation

6. No H/o tinnitus/vertigo/deafness No H/o nasal regurgitation/ nasal twang of voice/ hoarseness of voice No H/o difficulty in swallowing Able to shrug the shoulder / turn head from side to side No H/o difficulty in protruding tongue No H/o difficulty in rolling tongue from side to side No H/o memory / speech disturbances No H/o delusions/ hallucinations

7. No H/o difficulty in combing hair/ mixing food No H/o difficulty in turning from side to side No H/o difficulty in feeling clothes on the body No H/o tingling,numbness,pins and needle sensation over the body No H/ o difficulty in appreciating needle prock / warm and cold sensation in the body No H/o incoordination in the dark/ unsteadiness while washing face No H/o feeling the ground like cotton wool,

8. No H/ o unsteadiness while walking No H/o difficulty in negotiating narrow pathways No H/o difficulty in bringing food to mouth/ reaching the target No H/o involuntary movements No H/o difficulty in feeling bladder sensation No H/o difficulty in initiating /controlling micturition No H/o feeling of incomplete evacuation/ dribbling of urine No H/o bowel disturbances

9. No H/o giddiness while standing from lying posture No H/o lack of / abnormal sweating No H/o trauma/convulsions/ ear discharge No H/o recent vaccination

10. PAST HISTORY Patient is a known case of Diabetes mellitus on oral hypoglycemic agents for 10 years NO H/o previous hospitalization and covid exposure No H/o any other drug intake No H/o SHTN/TB/epilepsy/Ischemic heart disease No H/o previous similar episodes No H/ o recent respiratory illness/ diarrhea

11. PERSONAL HISTORY Patient consume mixed diet No H/o smoking/ tobacco usage/alcohol consumption Bowel and bladder habits are normal

12. FAMILY HISTORY No H/o similar episodes in the family No H/o contact with TB MENSTRUAL HISTORY Patient attained menopause 5 years back

13. SUMMARY A 58/F right handed person K/C/O DM presented with sudden onset of headache ,diplopia in all directions worse on looking towards right side and for far vision,drooping of eyelids,right sided facial pain with no history of loss of smell, colour vision,facial asymmetry,hard of hearing,difficulty in swallowing,shrugging of shoulder with no history suggestive of involvement of cortex,motor,sensory,cerebellum and autonomic nervous system. STRUCTURES INVOLVED: SECOND,THIRD ,SIXTH FIRST AND SECOND DIVISION OF TRIGEMINAL NERVE

14. GENERAL EXAMINATION Patient is conscious,oriented Well built and nourished No pallor /icterus/cyanosis/clubbing/lymphadenopathy No neurocutaneous markers No peripheral nerve thickening No external markers of TB/HIV No abnormal swelling of the neck

15. VITALS Pulse rate – 80 / min regular,normal rytm , character,felt in all peripheral vessels,no raddioradial or radiofemoral delay Blood Pressure- 120/80 mmHg measured in right upper limb in sitting posture Temperauture - 98.2 F Respiratory rate – 16/min thoraciabdominal

16. CNS EXAMINATION Patient is conscious Oriented to time ,place and person Apperance and behaviour – normal Affect – normal Intelligence – normal Memory – immediate,recent and remote – intact Abstract thinking/reasoning /judgement/Attention – normal Speech / articulation – normal Language – comprehension,repitition,Naming , reading and writing- intact MMSE - 26/30

17. CRANIAL NERVE EXAMINATION RIGHT Olfactory nerve Smell intact (coffee powder) Optic nerve Visual acuity 20/200[improved with pinhole] Colour vision normal LEFT intact 20/200 normal

18. RIGHT 1. Ptosis complete ptosis of right eye + 2.Position of the adducted and intorted Eye in primary Gaze 3.No nystagmus 4.Pupil size dilated (5mm) LEFT No ptosis normal 3mm

19. 5.Pupillary reflex
Right eye - Direct pupillary reflex is absent and consensual reflex is present Left eye Direct pupillary reflex is present and consensual reflex is absent
6.Accomodation reflex could not be tested

20. EXTRAOCULAR MOVEMENTS The primary gaze the right eye is adducted and intorted elevation,depression,abduction and extorsion are impaired. LEFT EYE – All extraocular movements are full and free.

21. RIGHT Trigeminal nerve Pain ,touch and impaired in V1,V2 Temperature. territory Clenching the teeth able to do Open mouth able to do Protrude jaw able to do Move jaw from able to do side to side LEFT intact in V1,V2,V3 territory able to do able to do able to do able to do

22. Corneal reflex On stimulating the right eye Direct corneal reflex is absent and consensual corneal reflex is absent On stimulating the left eye direct corneal reflex is present and consensual corneal reflex is present Conjunctival reflex. Right eye- Absent Left eye - present

23. RIGHT LEFT Present

24. Able to Raise the eyebrow Wrinkling of forehead present No Deviation of angle of mouth No nasolabial fold obliteration Taste sensation over anterior two third of tongue - normal

25. RIGHT Vestibulocochlear Nerve Whispering able to hear Watch test able to hear Rinne AC>BC Weber equally felt Absolute bone Conduction test same as examiner Oculocephalic reflex present LEFT Able to hear able to hear AC>BC equally felt same as examiner present

26. Glossopharyngeal nerve Uvula - midline Palatal movement - equal on both sides Gag reflex - present

27. Spinal accessory nerve Able to shrug the shoulder against resistance Able to move head from side to side against resistance bilaterally Hypoglossal nerve Able to protrude the tongue Tongue – no wasting, deviation,fasciculation Able to move the tongue from side to side

28. MOTOR SYSTEM RIGHT Bulk Upper limb nourished and normal Arm Forearm Lowerlimb Thigh Calf Tone Upper limb normal Lowerlimb normal LEFT Nourished and normal normal normal

29. RIGHT Power Shoulder Flexion 5/5 Extension 5/5 Abduction 5/5 Adduction 5/5 External rotation 5/5 Internal rotation 5/5 LEFT 5/5 5/5 5/5 5/5 5/5 5/5

30. RIGHT Elbow Flexion 5/5 Extension 5/5 Wrist Flexion 5/5 Extension 5/5 Supination 5/5 Pronation 5/5 Finger flexion 5/5 Finger extension 5/5 LEFT 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5

31. RIGHT Lower limb Hip joint Flexion 5/5 Extension 5/5 Abduction 5/5 Adduction 5/5 Knee Flexion 5/5 Extension 5/5 LEFT 5/5 5/5 5/5 5/5 5/5 5/5

32. RIGHT Ankle joint Plantar flexion 5/5 Dorsiflexion 5/5 Inversion 5/5 Eversion 5/5 LEFT 5/5 5/5 5/5 5/5

33. REFLEXES RIGHT Superfical reflexes + Abdominal + Cremastric + Anal + Plantar FLEXOR LEFT + + + + FLEXOR

34. RIGHT Deep reflexes
Upper limb Trapezius jerk 2+ Pectoral reflex 2+ Biceps 2+ Triceps 2+ Supinator 2+ Finger flexion 2+ Lower limb Knee 2+ Ankle 2+ LEFT 2+ 2+ 2+ 2+ 2+ 2+ 2+ 2+

35. COORDINATION Finger nose test - Able to perform Finger finger nose test - Able to perform Tapping in a circle - Able to perform Heel knee test - Able to perform Drawing a circle in air - Able to perform No dysdiadokinesia,tremor,nystagmus,titubation . Able to walk in a straight line No involuntary movements Gait - normal

36. SENSORY SYSTEM Sensation of touch ,pain, temperature,pressure , vibration,joint position normal in both upper and lower limb and trunk Rombergs test – negative Cortical sensation – intact Colour and temperature – normal No cyanosis/ abnormal sweating. No signs of meningeal irritation Spine and cranium – normal

37. SUMMARY A 58/F with h/o sudden onset headache asscociated with right sided facial pain , diplopia and ptosis.Exmination of the CNS showed invovment of third first and second division of trigeminal nerve and sixth nerve with no involvement of motor,sensory,cortex,cerebellum and autonomic nervous system

38. DIFFERENTIAL DIAGNOSIS 1.Cavernous sinus thrombosis 2.Superior orbital fissure syndrome 3.Tolosa hunt syndrome 4.Ophthalmoplegic migraine 5.Giant cell arteritis

39. THANK YOU