1. A 71-year-old diabetic and hypertensive male presented with 3 months of gradually worsening lower limb weakness. 2. On examination, he had wasting and weakness predominantly in his left lower limb with absent reflexes. Sensory examination revealed loss of vibration sense in his feet. 3. Imaging and laboratory results were ordered to investigate the cause of his progressive weakness.

1. TUESDAY GRAND ROUND
CASE PRESENTATION
AHMED
ELKHEZENDAR
Ahmed abdelnaser
13/ 6/ 2023
AL-AZHAR UNIVERSITY
Faculty of Medicine
Neurology Department

2. PERSONAL HISTORY
• A 71 years old male patient retired policeman Rt handed

3. COMPLAINT
• Weakness of both lower limbs of 3 months duration

4. HISTORY OF PRESENT ILLNESS
• The condition has started has started 3 month ago by subacute onset
lower back pain which was localized , throbbing ,some times stabbing
,moderate to sever ,increase with movement and at night , decreased
with rest and analgesia , radiating to both bottocks
• 1month later patient developed weakness in both lower limbes which
was left more than right , proximal more than distal , flexor more than
extensor associated with hypotonia completed within 1 month till patient
became wheelchair

5. 1.5 month later the relevant noticed wasting in the medial aspect of
the thigh of the both lower
Patient noticed worm like sensation at the anteriror part of the thigh
at the beginning of weakness then disappear now aday
patient start to complain 1 month ago from urine and stool incontinens

6. patient denay any sensory affection during
perioty of disease
Patient denay any associated fever allover
the course of disease
No history suggestive upper limbe affection
No history suggestive cranial nerve affection
No history suggestive cerebellar affection
No history suggestive troma ,headach or fits

7. • Born and live in giza
• Married
• Has 3 sibling tha youngest has 29 y
• Smoker
• No other special habit of medical important
Social history

8. PAST HISTORY
Diabetes uncontrolled for 25 year on oral treatment
Hypertensive
2 year ago Repair operation of left head femur fraction
No history of blood transfusion
No history of troma
No history of liver or kidney disese
No history of drug addiction .

9. • Irrelevent
Family history

10. FORMULATION
Male patient 71 years old diabetic uncontrolled and
hypertensive presente 3 month ago by gradual onset
progressive course weakness of both lower limb
 1st month lower back bony bain
2nd month lower motore weakness in both lower
limbe associated late with urine and stool incontinens
3rd month paitent became bed ridden

11. GENERAL EXAMINATION

12. • BP: 110/70
• Pulse: 84 beats/m, regular, average volume, equal on both sides.
• RR: 14 cycle/m.
• T: 37◦ C.

13. • Head and Neck: no characteristic facies, normal thyroid.
• Chest: fair air entry, no adventitious sounds.
• Heart: normal S1 & S2, no murmurs, gallops or rub.
• Abdomen: Lax abdomen, not tender, no detectable ascites or
suprapubic dullness.
• Skin : no rash, plaques only atorophic changes in both feet

14. NEUROLOGICAL EXAMINATION

15. MENTAL STATE
• The patient is fully conscious, attentive, well oriented to time, place,
person, with intact memory, depressed mood .
• MMSE : 25/30

16. SPEECH
• No dysarthia or aphasia

17. CRANIAL NERVES
• Olfactory: intact
• Optic:
 VA: Rt: 6/6; Lt: 6/6.
 Color vision: intact
 Visual field: NAD
 Fundus examination: diabetic retinopathy
• Occulomotor, Trochlear, Abducens:
 Intact ocular motility
 Pupil : RRR bilateral; Light reflex: intact both direct and indirect
 No nystagmus, No squint or INO

18. CRANIAL NERVES
• Trigeminal :
 Intact motor and sensory examination.
 Corneal reflex: intact
 Jaw reflex: just elicited
• Facial Nerve:
 No facial asymmetry
 Glabellar reflex: normal
• Vestibulo-Cochlear:
 Cochlear part: Intact
 Vestibular part: intact .

19. CRANIAL NERVES
• Glossopharyngeal, Vagus:
 Uvula: Centralized
 Palatal movement: Intact on both side
 Palatal& Pharyngeal Reflexes: present bilaterally
• Hypoglossal Nerve:
 Tongue: no wasting, abnormal movements or fasciculation.

20. MOTOR SYSTEM
Muscle state ,wasting and gattring in the smoth muscle of the hand
Upper limb Power ; full power
Reflexes;normal reflexes

21. Lower limbes
Inspection ; wasting in the medial side of the thigh and anterior
aspect of the leg
Power ; left more than right proximal more than distal abduction
more than adduction flexore more than extensor
Motor of the lower limbe

22. Hipe flexion G2
Hipe extention G3
HIPE abducition G-4
left lower limbe
HIPE adduction G 2
Knee flexor G2
Knee extensor G3
PLUNTER
EXTENSOR G3
PLUNTER FLEXOR
G4
Right lower limbe
Hipe flexion g3
HIPE EXTENTION G-4
HIPE ABDUCTION G4
HIPE ADDUCTION G3
KNEE FLEXOR G3
KNEE EXTENSORE G4
PLUNTER EXTENSOR G-4
PLUNTER FLEXOR +4
Motor of the lower limbe

23. REFLEXES
• Deep tendon reflexes:
• Areflexia of both ankle
• Areflexia of both knee
• Normal biceps, brachioradialis and triceps
• Superficial reflexes
 Abdominal: INTACT (upper, middle, lower)
 Plantar: Bilateral flexor planter reflex.
2+
0
0 0
2+ 2+
2+
2+
2+
0

24. SENSORY SYSTEM
• Superficial: glove and HIGH stock hypothesia
• Hypothesia at saddle area
• Deep: VIBRATION SENSATION LOST ON MEDIAL MALLEOLUS and
preserved at tibial tuobersty

25. CEREBELLUM
 No truncal ataxia.
 no ataxia on doing :
Finger to nose, finger to finger.

26. BACK
• No Scoliosis or kyphosis.
• No skin pigmentation.
• localized tenderness at the lower bake

27. OTHER
• positive strech signs
• No suprabupic dullness

28. LABORATORY TESTS
• AST = 29 U/l
• ALT = 31 U/l
• Creatinine = 1.3 mg/dl
• Urea = 40
• ESR = 55 (1st hour).
• Hb = 11 g/dl
• TLC = 7.9 k/ul
• Crp= 116

29. IMAGING