Clinical Case Presentation

Medical unit -8

Dr. Suresh Yadav

Dr. Suraj Rajpurohit
Case of 54 year old, right handed married female hindu (Dhoula devi)
patient, resident of Tonk.

She is house wife by occupation.

Admitted on 27 oct 2021.

History is given by patient herself and seems reliable.

 1. Back pain since 17 days.

2. Tingling sensations in both lower limbs since 15 days.

Chief 3. Tingling sensations in both upper limbs since 12 days.

complaints 4. Weakness in both lower limbs since 11 days.

5. Weakness in both upper limbs since 9 days.

6. Slurring of speech and difficulty in chewing since 8

days.
 Patient was asymptomatic 25 days back when
she developed fever for 4days for which she
took treatment from local hospital and got
History of relief.

presenting 7 days after fever she developed severe back

illness pain following which she developed tingling
sensation in both lower limbs starting from foot
and progressing proximaly towards inguinal
regions in 2 days.

In next 2 days she also developed tingling

sensation in both upper limbs
.

After 2 days she developed Weakness in both lower limbs noticed in form of
slipping of chappals ,repeated falls on attempting to walk along with buckling
of knee and inability to get up from the floor.

Initially she was able to walk with support, then weakness progresses to
the stage of inability that she was unable to able to walk with support and
got bedridden.
..

On next day she noticed difficulty in holding glass but able to raise
both arms above her head .

She then developed difficulty in speech and chewing with drooling

of saliva.
 Present status
At present patient is confined to bed and showing slight recovery .

She is able to raise her arms above head and able to hold glass
with her hands.

She is now able to get up from lying down position with support
and able to sit without support.

She is able to move her legs side by side in bed.

 No H/ o urinary incontinence or retention
No h/o difficulty in swallowing.

Negative No
No
H/o breathing difficulty.
H/o diurnal variation in weakness
History No
No
h/ o blurring of vision or double vision
h/ o loss of sensation over face
No h/o loss of taste sensation
No h/o vomiting and loose stool
Past history
No history of similar complaints in past
No history suggestive of DM, HTN , TB , Hypothyroidism.
Family history
No significant family history
Personal history
She is on mix diet (veg and non veg).
Appetite is normal
Regular bowel and normal bladder habits
Sleep is normal.
Non smoker , non alcoholic
Obs and Gynae history

Patient is post menopausal since 5 years.

She has 3 male and 3 female child youngest of

whom is of 25 years.
 Case summary
 A 54 year old ,right handed female presented with acute onset ,
rapidly progressive , symmetrical , ascending pure motor,
flaccid,areflexic quadriparesis with bilateral LMN type of facial palsy
without bowel bladder,respiratory ,bulbar and autonomic
involvement with preceding history of fever.

Now showing evidence of recovery.

GENERAL PHYSICAL EXAMINATION
Patient is conscious , cooperative, well oriented to time , place
and person

 She is lying comfortably in bed.

She is fairly built and nourished.

Vitals
Blood pressure is 122/70 mmHg in right arm in supine position
Pulse rate is 84 /min with regular rhythm, normal volume and
character. No radio-radial or radio-femoral delay and no vessel wall
thickening.
All peripheral pulses are palpable bilaterally and equally.
Respiration rate is 16 / min , regular rhythm, and
thoracoabdominal.
Temperature- patient is afebrile
 Head to toe examination
Greying of hairs is present
Eye …Sclerae– white
Conjunctivae – pink
No pallor
No icterus
No clubbing
No cyanosis
No edema
No significant lymphadenopathy
 CNS EXAMINATION
1. Higher mental function are normal
She is right handed person
Orientation – time / place – normal
Attention – Normal
Memory – normal
Language – normal
Speech – normal

2. Cranial nerves -

All cranial nerves are normal except right and left 7th cranial nerve.
VII NERVE

Absence of wrinkles over forehead on both sides.

Bell’s phenomenon is present.
Widening of palpabral fissure in both eyes.
Slight obliteration of both nasolabial folds.
She is unable to puff up the cheeks.
Taste sensation preserved in anterior 2/3 of tongue
 Motor system
Attitude – supine with arms by the side .

Both upper limbs – slight abduction at shoulder, flexion at

elbow and extension at wrist .

Both lower limbs – extension at hip, knee and ankle

Bulk- bilateral symmetrical , no wasting .

Parameters Right ( cm ) Left ( cm )

Arm circumference 31 31

Forearm 24 24

Thigh 46 46

Calf 33 33
 TONE:at the time of admission

PARAMETER LEFT RIGHT

Upper limb
1. Flexor hypotonia hypotonia
2. Extensor hypotonia hypotonia

Lower limb
1. Flexor hypotonia hypotonia
2. Extensor hypotonia hypotonia
 TONE:at present

PARAMETER LEFT RIGHT

Upper limb
1. Flexor hypotonia hypotonia
2. Extensor hypotonia hypotonia

Lower limb
1. Flexor hypotonia hypotonia
2. Extensor hypotonia hypotonia
Power
Parameters Left ( at the time Left ( at present) Right ( at the time Right ( at
of admission) of admission) present)
1. Neck
• Flexors 4 4 4 4
• Extensors 4 4 4 4
2 shoulder
• Flexion 4 4 4 4
• Extension 4 4 4 4
• Abductions 4 4 4 4
• Adduction 4 4 4 4
• Internal rotation 4 4 4 4
• External 4 4 4 4
rotation
Parameters Left ( at the time of Left ( at present) Right ( at the time Right
admission) of admission) ( at
present)
3. Elbow

Flexion 4 4 4 4
Extension 4 4 4 4

4. Wrist
Flexion 3 4 3 4
Extension 3 4 3 4

5. Hand grip weak fair weak fair

6 . Trunk muscles Weak Good Weak Good

Parameters Left ( at the time of Left (at present) Right ( at the time Right ( at
of present)
admission) admission)
7.Hip joints
Flexion 1 2 1 2
Extension 1 2 1 2
Adduction 1 2 1 2
Abduction 1 2 1 2

8. knee joint
Flexion 1 2 1 2
Extension 1 2 1 2
9.Ankle joints
Planter flexion 1 3 1 3
Dorsiflexion 1 3 1 3
 Parameters • Right Left

Reflexes Superficial reflexes

• Corneal present present
• Abdominal absent absent
• Planter mute Mute

Deep tendon reflexes

• Jaw Absent Absent
• Biceps Absent Absent
• Triceps Absent Absent
• Supinator Absent Absent
• Knee Absent Absent
• Ankle Absent Absent
 Parameters Right Left

Sensory systems Spinothalamic sensation

• Temperature Intact Intact
• Pressure Intact Intact
• Pain Intact Intact

Posterior column sensation

• Fine touch Intact Intact
• Vibration Intact Intact
• Proprioception Intact Intact

Cortical sensation
• Tactile localization Intact Intact
• Two points discrimination Intact Intact
• Stereognosis Intact Intact
• Graphesthesia Intact Intact
.

Gait- could not be examined.

No signs of meningeal irritation

Skull and Spine are normal ( no tenderness , no deformity )

Diagnosis Functional : A 54 year old ,right handed female
presented with acute onset , rapidly progressive ,
symmetrical , ascending pure motor,
flaccid,areflexic quadriparesis with bilateral LMN
type of facial palsy without bowel
bladder,respiratory ,bulbar and autonomic
involvement with preceding history of fever.

Anatomical : Polyradiculoneuropathy
.

Thank you