2. • NAME : Prakash Chandra
• AGE : 57 yrs
• GENDER : male
• Occupation : grocery store owner
• HANDEDNESS : Right
• EDUCATION : primary school
• ADDRESS : orissa
3. HISTORY OF PRESENTING ILLNESS
Nov 2023:
The patient was apparently alright, then he started developing pain in both calf muscles, insidious in
onset, gradually progressive, more during night time a/w cramps. The patient got symptomatic
treatment in the local hospital with painkillers.
4. • Dec 2023 :
• The patient started noticing walking difficulty in both limbs, which was insidious in onset,
gradually progressive with no aggravating and relieving factors. He describes it as his left leg toe
touches the ground first followed by the heel when he walks. The patient was able to keep his
right leg normally.
• He also noticed difficulty in gripping the footwear with his left leg more then right leg, but he was
aware of slipping of footwear.
• He gives history of lower back ache with no diurnal variation and no radiation to the leg.
5. Jan 2024
• Patient gives h/o difficulty in getting up from the floor.
• Patient gives h/o tingling sensation in both lower limb ,insidious in onset , gradually progressive ,
initially started at big toe and other fingers progressed till mid ankle.
• h/o urinary disturbance in the form of increased frequency at night with no hesitancy or urgency.
6. • No h/o twitching of muscles, no h/o sensory and motor symptoms in upper limbs.
• no h/o fever and rashes ,joint pain
• No h/o cranial nerve involvement
• No h/o incoordination
• No h/o trauma
• No h/o weight loss
• no h/o feeling band like sensation over the abdomen
• No h/o difficulty in turning side to side in the bed & getting up from supine position
7. PAST HISTORY
• NO HISTORY OF SIMILAR COMPLAINTS IN THE PAST .
• Type 2 dm since 4 years on OHA , (uncontrolled)
FAMILY H/O :
not contributory
8. PERSONAL HISTORY
• Diet : mixed
• Appetite : good
• Sleep : undisturbed
• Bowel : normal
• Bladder : increase frequency
• Chronic smoker since 20 years, ethanol consumption 60 ml daily for 20 years
9. SUMMARY
• 57 year old male diabetic , h/o chronic smoking and ethanol consumption came with
asymmetrical onset of walking difficulty ( L>R) S/O distal lower limb weakness ( L>R) ,f/b proximal
lower limb weakness with sensory involvement in lower limb ( L>R) with increased urinary
frequency without upper limb involvement
10. GENERAL PHYSICAL EXAMINATION
• The patient is conscious, oriented & cooperative.
• Height – 162 cm
• Weight – 64 kg
• Pulse – 88 regular normal volume, character, condition, no radio radial or radio femoral delay.
• All Peripheral pulses felt
• BP – 120/70 mm Hg on right arm in sitting position
• RR- 16 cpm thoraco-abdominal type
• No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.
• No raised JVP
• No neurocutaneous markers.
11. SYSTEMIC EXAMINATION
Central nervous system-
Higher mental functions
• Patient is conscious, oriented to time place and person.
• Registration –normal
• Attention and calculation- normal
• Recall – normal
• Language
naming ,repetition – Normal
3 step command – normal
• Reading –normal
• Writing – normal
• Copying - normal
Speech –spontaneous with intact comprehension,fluency.
Memory –immediate,recent ,remote –normal.
12. CRANIAL NERVE EXAMINATION
CRANIAL NERVES RIGHT LEFT
Olfactory N N
Optic
Visual acuity N N
Field of vision, colour vision N N
Fundoscopy
Occulomotor, trochlear, abducent
Pupils
Direct & indirect light reflex
Accommodation reflex
EOM
Nystagmus
3mm regular
Present
N
N
Absent
3mm regular
Present
N
N
Absent
13. Cranial nerves Right Left
Trigeminal nerve N N
Facial nerve N N
Vestibulocochlear nerve N N
Glossopharyngeal nerve N N
Vagus nerve N N
Spinal accessory nerve N N
Hypoglossal nerve N N
19. DEEP TENDON REFLEXES RIGHT LEFT
BICEPS 3+ 3+
TICEPS 3+ 3+
SUPINATOR 3+ 3+
KNEE 2+ 2+
ANKLES 2+ 2+
20. SUPERFICIAL REFLEXES RIGHT LEFT
CORNEAL PRESENT PRESENT
CONJUNCTIVAL PRESENT PRESENT
ABDOMINAL-UPPER
MIDDLE
LOWER
PRESENT
PRESENT
PRESENT
PRESENT
PRESENT
PRESENT
PLANTAR FLEXOR EXTENSOR
ANAL REFLEX NOT DONE NOT DONE
21. COORDINATION
• UPPER LIMBS: NORMAL ON BOTH SIDES
• LOWER LIMBS : NORMAL
• NO CEREBELLAR SIGNS
• GAIT-LEFT FOOT DRAGGING
22. SENSORY SYSTEM
• SUPERFICIAL SENSATIONS
1. FINE TOUCH- DECREASED (20 %) ON LEFT ON LEFT DORSUM OF FOOT.ALL OTHER AREAS NORMAL.
2. PIN PRICK SENSATION-DECREASED (20%) ON LEFT DORSUM OF FOOT..ALL OTHER AREAS NORMAL.
• JOINT POSITION SENSE- INTACT
• DEEP SENSATIONS
1. PAIN- DECREASED( 20%) ON LEFT DORSUM OF FOOT ,TEMPERATURE- DECREASED 20%– ON LEFT ON LEFT
DORSUM OF FOOT
23. • No signs of meningeal irritation.
• OTHER SYSTEM EXAMINATION-
• CVS- S1S2 HEARD ,no murmur
• RS- B/L NVBS HEARD
• PER ABDOMEN- SOFT NON TENDER
