A 52-year-old female presented with gradual, progressive bilateral lower limb weakness over one year, with no sensory, bowel, or bladder involvement. Examination revealed normal cranial nerve function, higher mental functions, and muscle tone, while deep tendon reflexes were present. Differential diagnoses considered include myopathy, neuropathy, motor neuron disease, and neuromuscular junction disease, with supporting evidence for myopathy and excluding significant sensory loss.

1. Case presentation
By : Dr. Gyaneshwar (DNB Resident)
Moderator : Dr. Kislaya Kamal (SR
Medicine)

2. Patient particulars
• My patient Rajkumari, 52 years old, female, Housewife, resident of
Bulandshahar, UP
• Date of admission - 15th April 2024
• Date of examination - 17th April 2024

3. Chief complaints
• Weakness of both lower limb for 1 year

4. History of present illness
• Patient was apparently asymptomatic 1 year back when she started
feeling weakness in her left lower limb, which was Incidious in onset and
gradually progressive.
• Initially she had little difficulty in wearing and holding slipper in left leg, but
she was able to get up from floor and was able to walk and do her routine
work. Within 6 months it progressed to involve the right lower limb also.
She found it difficult to get up from a chair or squatting position.

5. History of present illness
• For last 4 months she is not able to walk. She also noticed difficulty in
rolling over the bed and getting up from supine position.
• There is no difficulty in opening the jars and holding objects like cup of tea
or comb. There is no difficulty in overhead reach and difficulty in combing
hair. She also didn’t have any difficulty in raising head from supine and
holding it.

6. • There is no diminished vision, double vision, drooping of eyelids or facial
asymmetry.
• No history of slurring of speech, difficulty in swallowing and nasal
regurgitation.
• No history of vertigo or hearing abnormality.
• No history of changes in memory, social disinhibition,
delusion/hallucinations.
History of present illness

7. • No history of altered sensorium, fall/injury in lower back.
• No history of fever, weight loss, night sweats or band like sensation in
trunk.
• No history of bowel and bladder disturbances.
• No history of numbness or tingling sensation.
• No history of loose stools, pain abdomen or running nose prior to the
presentation.
History of present illness

8. Past History
• No history of Diabetes mellitus, hypertension, ischemic heart disease or
tuberculosis.
• No history of any significant drug intake.

9. Personal History
• Patient consumes mixed diet. No bladder and bowel disturbances. No
sleep disturbances.
• Appetite is normal.
• No history of any substance abuse.

10. Family History

11. Summary
• A 52 years old female without any comorbiditiy presented with chronic,
progressive, persistent bilateral lower limb weakness with no sensory,
bowel or bladder involvement.

12. General examination
My patient was conscious , cooperative, obeying commands and lying supine
on bed before examination, right handed,
Vitals :-
• Pulse - 80beats per minute, regular , normal volume and character, all
peripheral pulses palpable, no vessel wall thickening, no radio-radial or
radio-femoral delay.
• Blood Pressure - 122/72 mmhg in right arm in supine position.
• Respiratory Rate - 16 breaths per minute, regular, abdominothoracic type
• Jugular venous pulse - not visible.

13. General examination
• Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema are not seen
• Head to toe examination - normal hair, Poor oral hygiene. No atrophy of
thenar, hypothenar eminences.

14. Higher mental functions
• Appearance and behaviour - normal
• Memory - normal
• Attention - normal
• MMSE (30/30)
1. Orientation - normal to time and place (10)
2. Registration - named 3 objects (3)
3. Attention and calculation - normal (5)
4. Registration recall - normal (3)
5. Language - following commands, naming two objects, reading and
following, can draw shapes, can repeat, can write a sentence (9)

15. Higher mental functions
• Speech – No slurring of speech
• Able to produce spontaneous speech, intact comprehension and repetition
• No agnosia, hallucination, delusion, neglect, prosody

16. Cranial nerve examination
A) Olfactory nerve - normal smell perception from both nostrils
B) Optic nerve -
• Visual acuity - finger count at 6 feet is present.
• Visual field - normal ( done by confrontation method ) in both eyes
• Colour vision - normal
C) Oculomotor, Trochlear, Abducens -
• Eyelids - no ptosis, no lid retraction
• Position of eyeballs at rest - no squint, normal sized pupils, no exophthalmos
or enophthalmos
• Light reflex - direct and consensual light refex are present
• Accommodation reflex - present
• Normal eyeball movements in all 8 directions, no nystagmus noted

17. Cranial nerve examination
D) Trigeminal nerve -
a) Sensory - normal pain, touch and temperature sensation over V1, V2, V3
divisions
b) Motor - no jaw deviation on mouth opening, masseters well palpated on
jaw clenching, jaw protrusion was normal
c) Reflexes - 1) Jaw jerk- can not be elicited.
2) Corneal reflex - present

18. Cranial nerve examination
E) Facial nerve -
1. Motor - on inspection, facial symmetry present, nasolabial fold normal bilaterally,
no atrophy or fasciculations , no involuntary movements or eye blinking
• Frontalis - forehead wrinkling present on both sides.
• Orbiculares oculi - able to close both eyes forcibly
• Levator anguli oris, zygomatic major and minor, depressor angulli oris, buccinator
and risorius - able to show teeth and no deviation of face.
• Orbicularis oris and buccinators - patient is able to blowout cheeks both side and
resistance felt on deflating by external compression bilaterally.
• Platysma - folds of muscle seen on clenching teeth and depressing angle of mouth
left side
2. Sensory - normal taste sensation on anterior 2/3rd of tongue
3. Secretory - Schirmer’s test not done

19. Cranial nerve examination
F) Vestibulocochlear nerve - a) Rhinne- AC> BC
b) Weber- no lateralisation
c) no vertigo or nystagmus
G) Glossopharyngeal and Vagus nerves
• No deviation of tongue on protrusion, asymmetry in tongue shape
• No deviation of faucial pillars
• Bilateral elevation of anterior faucial pillars on eliciting gag reflex
• No slurring of voice
• No difficulty in swallowing
H) Spinal accessory nerve - Able to shrug both shoulders.
I) Hypoglossal nerve
• No tongue deviation, tongue fasciculations present, symmetrical in shape
• Power of tongue - normal bilaterally

20. Motor system examination
• Attitude - normal attitude of all four limbs
• Bulk -1) Right arm- 25 cm. 2) left arm- 25 cm
3) right forearm- 19 cm. 4) left forearm- 19 cm
5) right thigh- 43 cm. 6) left thigh- 43 cm
7) right calf- 26 cm. 8) left calf- 26 cm
• No atrophy of thenar eminences,
• Normal bulk shoulder girdle muscles

21. Motor system examination
JOINT ACTION RIGHT LEFT
1) NECK FLEXION 5
EXTENSION 5
2) SHOULDER EXTENSION 5 5
FLEXION 5 5
ADDUCTION 5 5
ABDUCTION 5 5
3) ELBOW EXTENSION 5 5
FLEXION 5 5
POWER

22. Motor system examination
POWER
JOINT ACTION RIGHT LEFT
4) HIP FLEXION
EXTENSION
ADDUCTION
ABDUCTION
5) KNEE FLEXION
EXTENSION
6) ANKLE PLANTAR FLEXION
DORSIFLEXION

23. Motor system examination
• Trunk -
• Hand grip - Normal bilaterally
Reflexes :
Patellar Clonus - absent
Ankle Clonus - absent
Hoffmann’s reflex - Negative on both upper limb

24. Motor system examination
SUPERFICIAL RIGHT LEFT
CORNEAL + +
ABDOMINAL
PLANTAR
DEEP TENDON REFLEXES (GRADING)
BICEPS
SUPINATOR
TRICEPS
KNEE JERK
ANKLE JERK
Reflexes

25. Sensory system examination
PRIMARY SENSATION R L
TOUCH NORMAL NORMAL
PAIN NORMAL NORMAL
TEMPERATURE NORMAL NORMAL
VIBRATION NORMAL NORMAL
JOINT POSITION NORMAL NORMAL
CORTICAL SENSATION
TWO POINT
DISCRIMINATION
NORMAL NORMAL
STEREOGNOSIS NORMAL NORMAL

26. Cerebellum
• Finger nose test - No past pointing with both hands
• Dysdiadokokinesia- Normal with both hands
• Heel knee test- Can not be elicited
• Tandem walking- Can not be assessed.
• Gait- Can not be assessed.
• No signs of meningeal irritation

27. Other system examination
• Respiratory system - Chest symmetrical, bilateral air entry present, no
added sound
• Cardiovascular system - S1, S2 heard, no murmur, apex beat in 6th ICS,
lateral to mid clavicular line, No parasternal heave, No epigastric
pulsations, JVP not elevated.
• Abdominal examination - soft, non tender, bowel sound heard, no
organomegaly.

28. Summary
• A 52 years old female without any comorbiditiy presented with chronic,
progressive, persistent bilateral lower limb weakness without any cranial
nerve, higher mental function, bowel or bladder involvement, with normal
muscle tone, deep tendon reflexes and sensory.

29. Differential diagnosis
DDs Points In favour Points Against
Myopathy
DTR +, muscle Bulk - normal
Tone - Normal, sensory - intact
Distal to proximal progression
Tongue Fasciculations, Age of onset
Neuropathy
Distal to proximal progression
Tongue Fasciculations
No Sensory involvement
DTR+
LMN predominant MND
Tongue fasciculations
Planter - mute
Sensory - intact
Tone - Normal
DTR +
NMJ disease
DTR +, muscle Bulk - normal
Tone - Normal, sensory - intact
No diurnal variations
No Facial/ Cranial involvement