2. Patient name Mr Sobran Lal ,49 years old male ,resident of Kheri ,
Hindu by religion. He is a mason by profession. History is given by
patient himself and seems to be reliable.
CHIEF COMPLAINTS-
• Weakness in right upper and lower limb since 2 years
• Difficulty In walking since 9 months.
3. HISTORY OF PRESENT ILLNESS
• Patient was apparently asymptomatic 2 years back when he started
developing tingling sensation on right hand which got resolved within
one month after taking medication from local practioner.
• Again patient developed tingling sensation and weakness in right
hand which was insidious in onset, initially started from right hand
and gradually progressed to right upper limb and right lower limb.
• He initially had difficulty in getting up from squatting position and
difficulty in walking (patient used to walk without support initially )
• After few months weakness progressed such that patient required the
help of family members to move around.
4. • He also complaints of loss of sensation in right upper and lower limb
where he was not able to appreciate clothes,hot and cold water
sensations.
• He also developed feeling of numbness in left lower limb since 6
months.
• there is no history bowel and bladder incontinence.
5. • History of lower back pain since 2 years .
• No history of trauma and injury.
• No history of recent drug intake intrathecally or spine surgery .
• No history of eveneing rise of temperature, cough, expectoration,
weight loss, bone pain, swelling in the back or any tubercular contact.
• No history arthralgia, photosensitivity, rash
• No history high risk behaviour.
• There is no history of altered sensorium, loss of conciousness or
convulsions.
6. PAST HISTORY :
• The patient had no history of any similar episodes in the past.
• Pt is a known case of hypertension since 9 months
• No history of diabetes,asthma ,tb,epilepsy.
FAMILY HISTORY:
• No similar complaints in the family
7. PERSONAL HISTORY
• Consumes mixed indian diet
• Patient is an occasional alcoholic for 30 years
• occasional bidi smoker for 30 years
• normal sleep
• normal bowel and bladder habits
• denies any high risk behaviour
8. SUMMARY
• 49 Year old male patient resident of Lakhimpur presented with right
sided upper limb and lower limb weakness since 2 years which was
gradually progressive in nature ,without any involvement of bowel
and bladder.
9. GENERAL EXAMINATION
• Middle aged male patient examined in a well lit room in supine
position,with due consent.
• Patient is concious, cooperative ,and well oriented to time ,place and
person .
• Vitals:
• Pulse- 70/min in left radial artery, rhythm and volume are normal,no
radio-radial/radiofemoral delay,all peripheral pulses felt.
• BP-120/78 mmhg taken in supine position in the left brachial artery.
• Temperature- 98.4F in right axilla.
• RR-14/Min ,Abdominothoracic
10. • JVP normal
• No Pallor, Icterus, Cyanosis, Clubbing , or Edema
• No lymphadenopathy
• No kyphoscoliosis or any spinal deformity seen. Skin over the back is
normal. No gibbus ,no spinal tenderness present.
12. CRANIAL NERVES EXAMINATION
RIGHT LEFT
I.
Olfaction
Intact Intact
II.
Visual acuity,color vision
,pupillary reflex ,field of vision
intact intact
III, IV, VI
Extraocular movements
,accomodation
intact intact
V
Sensory ,motor ,reflexes
(corneal,jaw jerk)
intact intact
13. RIGHT LEFT
VII
raising eye brows
shutting eyelids tightly
clenching the teeth
blowing the cheeks
not
intact
VIII
Rinne test
Weber test
bc>ac
lateralised to right ear
intact
IX, X
Gag reflex uvula
intact intact
XI
Shoulder shrugging, head
turning
decreased present
XII
Tongue movements
intact intact
14. MOTOR SYSTEM EXAMINATION
• Attitude - Patient is lying on bed comfortably with arms by his side
,legs extended at knees
RIGHT LEFT
ARM 24 24
FOREARM 20 20
THIGH 39 39
LEG 28 28
