Polio mbbs

1. LONG CASE
EXAMINATION OF NERVOUS SYSTEM
KHEMESWAR AGASTI
3rd Year Junior Resident
Department of Medicine
S.C.B. Medical College & Hospital,
Cuttack,ODISHA

2. Patient details
Name-Miss XYZ
Age : 22 years
Sex :female
Religion: Hindu
Address:sundergarh,odisha
occupation: Tailor
Handedness: Right handed person
Date of admission -10.4.24
Informant: patients herself

3. PRESENTING COMPLAINTs
• Neck pain- 5 months
• Weakness of bilateral upper limb ~5 months
• Weakness of bilateral lower limb ~ 4.5 months
• Wasting of hand muscle-1 month

4. HISTORY OF PRESENT ILLNESS
• Patient was in her usual state of health 5 months back
• To start with she developed pain in her neck which was insidious in onset ,dull &
diffuse in nature without any radiation and no relieving or aggravating factors.
After 4-5 days she felt weakness in her neck which was also insidious in onset and
progressive in nature ,initially her head was falling forward while sitting for doing
tailoring activity ,and could lift her head with difficulty.
• Then after 2-3 days she experienced pain in the left shoulder joint and elbow joint
which was dull aching in nature without any swelling or radiation and neither
associated with stiffness nor progressive, and she felt weakness In her left upper
limb which was insidious in onset and gradually progressive, initially she
experienced difficulty in raising her arms above head, as she had difficulty in
reaching for objects placed in upper shelf, difficulty in wearing dresses and
applying soap on her upper part of body
• After 7 days she also experienced similar weakness in her right upper limb, as she
had difficulty in taking bath and pouring water above her head and difficulty in
reaching her hand above, to comb her hairs.

5. • After 6-7 days patient developed pain in bilateral hip joint and
weakness in both the lower limbs and initially she had difficulty in
getting from squatting position while doing daily activities, like after
bathroom, was using her hands on the floor & then thighs for
support, but had no joint pain either in knee or ankle Weakness was
insidious on onset and was gradually progressive
• she also had difficulty in climbing stairs as experienced by unable to
lift thigh and put on next step and difficulty in getting up from chairs
and was taking the help of family members for getting up
• After few days she also had difficulty in paddling the sewing machine
in her left foot, then she started using her right foot for paddling ,and
after few days she couldn’t do the same with right foot also
• Then After few days she had difficulty in getting up from lying position
and she needed help of another family member to lift her up

6. • Gradually she had difficulty in bending her head forward while trying to
get up from sleeping position and difficulty in lifting her head up above
the pillow .
• 1 month back she noticed gradual wasting of her hand muscles, and she
complained of gradual difficulty in holding objects in her hand and she was
not able to do her sewing activity and unable to hold any object tightly
• There was also history of intermittent low grade fever with pain in the
weakening muscle(myalgia)
• And patient also complained of dysphagia to solid only ,in the late phase
of deglutition as experience by feeling of something sticking in the chest
during deglutition, which is improved now
• She can differentiate between hot and cold and feels the touch of the
clothes over her body

7. • No fasciculation
• No fatiguability,
• No diurnal variation of weakness
• No history of dropping of eyelids
• No history of diplopia
• No history of contracture
• No history of exercise intolerance
• Nom history of cola coloured urine
• No history of dry cough or SOB ,cutaneous calcinosis
• No history of dysarthria
• No history of any abnormal movements in any part of
body

8. • No h/o change in voice
• h/o bowel bladder incontinence
• No hearing difficulty
• No imbalance or swaying while walking
• No early morning stiffness
• No h/o rashes, no alopecia, or oral ulcer
• No history of trauma.
• No history of headache, loss of consciousness, seizures.

9. HISTORY OF PAST ILLNESS
• No such similar illness episode in past
• Not a known case of Diabetes or HTN, asthma or any
thyroid or autoimmune diseases
• No history of any malignancy.

10. PERSONAL HISTORY
•Belongs to lower socioeconomic group.
•Studied up to 10th standard.
•Unmarried
•Takes both veg and non veg diet.
•No addictions
•Bladder bowel habits are regular
FAMILY HISTORY
Born out of non consanguine marriage
No similar history present in her family.

11. TREATMENT HISTORY
She was treated locally at a physio therapy center and received some
medications
Now She is admitted to FMW2 , Department of medicine, SCBMCH
from 10.4.24 and currently receiving:
1. Tab prednisolone 40 mg 1 tab OD
2. Inj pantoprazole 40mg IV OD
3. Inj ceftriaxone 1mg IV BD
and the neck drop, arthralgia and dysphagia subsided but weakness
is still there

12. SUMMARY
• A 22 Years old female tailor by occupation presented with ,
insidious onset progressive weakness in both upper limbs
initially proximal to start with then distal, and progressive
weakness of both lower limbs proximal more than distal with
truncal, neck and oesophageal muscle weakness ,with no
sensory involvement, no bladder,bowel dysfunction, with
history of intermittent fever, myalgia and arthralgia.

13. GENERAL EXAMINATION
• Thin body built
• Length = 152cm, Weight = 34 kg, BMI=14.7KG/M2
• There is pallor, no icterus, cyanosis, clubbing, pedal edema or
enlarged lymph nodes.
• JVP is not raised.
• No thyromegaly
• Skin, Hair, Nail Condition- Normal
• Neurocutaneous marker –Absent
• Acne vulgaris grade 2 and grade 3 in face
• Presence of dressing over right thigh

14. Pulse: 88/min, regular, normal in volume & character, no brachio-
femoral delay, no radio radial , arterial wall just palpable, all
peripheral pulses are well felt.
Blood Pressure: 114 /76 mm of Hg Right arm supine position.
Respiratory rate: 18 /min, regular, abdomino thoracic.
Temperature - 98.6° F.

15. EXAMINATION OF NERVOUS SYSTEM
HIGHER MENTAL FUNCTION:
• Pt is Conscious,
• Oriented to time, place and person.
• Speech is normal.
• Normal memory and intelligence.
• No delusion, hallucination.

16. EXAMINATION OF THE CRANIAL NERVES
1.Olfactory nerve : Normal
• No Anosmia
• No Parosmia.

17. 2. Optic Nerve
• Fundoscopy:Normal
RIGHT LEFT
Visual acuity Normal Normal
Color Vision Normal Normal
Field of Vision Normal Normal

18. 3.Oculomotor, Trochlear, Abducens Nerve:
• No Ptosis , Extraocular movements are normal in all
directions.
• Pupils are of normal size and shape in both eyes.
• Light reflex:
• Accommodation reflex present.
RIGHT LEFT
DIRECT PRESENT PRESENT
CONSENSUAL PRESENT PRESENT

19. 4. Trigeminal Nerve:
• Sensations over face normal.
• Corneal reflex present on both side
• No weakness of muscles of mastication.
• Jaw jerk not elicited
5. Facial nerve
• No weakness of facial muscles.
• Taste sensation over anterior 2/3rd
of tongue intact.

20. 6. Vestibulocochlear Nerve :
• Rinnes test: positive.
• Weber’s test not lateralised.
7. Glossopharyngeal & Vagus Nerve:
• Palatal movement bilaterally normal.
• Gag reflex present.

21. 8. Accessory Nerve :
• weakness of sternocleidomastoid or trapezius.
9. Hypoglossal Nerve :
• No atrophy and fasciculation of tongue.
• No deviation of tongue to any side.

22. MOTOR SYSTEM EXAMINATION
1.Attitude: patient was lying supine position with both lower limb
extended at hip and knee
2.BULK: patient looks thin built, no visible fascination
visible atrophy of supraspinatus and small muscles of hand
3.TONE
Upper limb : hypotonia
Lower limb : hypotonia
RIGHT LEFT
ARM 19cm 18cm
FOREARM 18cm 17cm
THIGH 34cm 34cm
LEG 27cm 27m

23. 3. POWER:
JOINT MOVEMENT RIGHT LEFT
Shoulder Abduction 2/5 2/5
Adduction 2/5 2/5
Flexion 2/5 2/5
Extension 2/5 2/5
Elbow Flexion 2/5 2/5
Extension 2/5 2/5
Wrist Flexion 3/5 3/5
Extension 3/5 3/5
Handgrip weak weak

24. JOINT MOVEMENT RIGHT LEFT
Hip Abduction 2/5 2/5
Adduction 2/5 2/5
Flexion 2/5 2/5
Extension 2/5 2/5
Knee Flexion 2/5 2/5
Extension 2/5 2/5
Ankle Dorsiflexion 3/5 3/5
Plantarflexion 3/5 3/5
Trunkal muscles - weak
Neck muscles - weak

25. 4) REFLEXES
DEEP TENDON REFLEXES
Right Left
Upper Limb Biceps absent absent
Triceps absent absent
Supinator absent absent
Lower Limb Knee diminished diminished
Ankle absent absent

26. SUPERFICIAL REFLEXES :
1. Plantar : B/L flexor
2. Abdominal reflex : present

27. CEREBELLAR SIGNS:
upper limbs: could not be done due to severe weakness
Lower limbs:could not be done
GAIT:
waddling gait
INVOLUNTARY MOVEMENTS - Absent

28. SENSORY EXAMINATION
All primary modalities of sensations like pain, touch,
temperature, proprioception, joint position and vibration are
intact

29. AUTONOMIC NERVOUS SYSTEM
• No resting tachycardia or bradycardia
• There is no constipation and urinary retention.
SKULL AND SPINE:
No Spinal tenderness ,no scoliosis or kyphosis
MENINGEAL SIGNS- absent
PERIPHERAL NERVE : neither thick nor tender

30. EXAMINATION OF CARDIOVASCULAR SYSTEM
INSPECTION :-
• Precordium normal in shape
• No dilated veins and visible scars seen
• Apical impulse not visible
• No other pulsation seen.
PALPATION:-
• Apical impulse -present in left 5th
ICS , ½ inch medial to
Mid clavicular line, normal in character.
• Pulmonary area : P2 not palpable.
• No thrill.

31. PERCUSSION:-
• 2nd
left intercostal space - resonant
• Cardiac dullness starts from left 3rd ICS & does not extend
beyond the apex.

32. AUSCULTATION:-
1) MITRAL AREA:
• 1st
heart sound normal
• No added sound.
• No murmur
2) PULMONARY AREA :
• Pulmonary Component of 2nd
Heart Sound Normal
• No Split
• No added sound

33. 3) AORTIC AREA :
• Aortic component of 2nd heart sound normal
• No added sound
• No murmur
4) TRICUSPID AREA:
• 1st
heart sound heard normal
• No murmur
5) NEOAORTIC AREA:
• No murmur

34. EXAMINATION OF RESPIRATORY SYSTEM
UPPER RESPIRATORY TRACT-normal
EXAMINATION OF CHEST:
INSPECTION :-
• Trachea appears to be central in position
• Apical impulse not visible
• Chest bilaterally symmetrical
• Bilateral Chest movement equal
• No paradoxical chest movement.

35. PALPATION:-
• Trachea is confirmed to be central
• Apical impulse is present in left 5th
ICS ½ inch medial to
MCL
• Chest expansion is 5 cm
• Vocal fremitus is normal
• There is no Intercostal tenderness

36. PERCUSSION :-
• Direct percussion over clavicle is normal bilaterally
• Percussion over left and right hemithorax is normally
resonant
AUSCULTATION :-
• Normal bilateral vesicular breath sound heard.
• Normal vocal resonance bilateral.
• No adventitious sound.

37. EXAMINATION OF GI SYSTEM
Mouth and oral cavity normal.
INSPECTION:-
• Shape of abdomen is normal
• Umbilicus central & inverted
• No engorged vein, no visible peristalsis
PALPATION:-
• Liver not enlarged, Spleen not palpable
PERCUSSION:-
• Abdomen is tympanitic.
• no shifting dullness
AUSCULTATION:-
• Bowel sound 3-4/min
• DRE - normal

38. EXAMINATION OF MUSKULO SKELETAL SYSTEM
GAIT
waddling gait
ARM
normal
LEGS
normal
SPINE-
normal

39. SUMMARY
A 22 year old Hindu female presented with insidious onset
gradually progressive symmetrical proximal > distal weakness of
bilateral upper limbs and lower limb with truncal and neck
muscle weakness and pharyngeal involvement and later wasting
of muscles of hand, with intermittent fever, myalgia and
arthralgia, without any sensory involvement or bowel bladder
involvement over 5 months.
On nervous system examination there is pure motor LMN
quadriparesis (proximal>distal) suggested by decreased bulk,
decreased tone, decreased power (2/5 proximally and 3/5
distally) in B/L upper and lower limb and diminished reflex, along
with oesophageal, truncal and neck weakness.

40. STRUCTURES INVOLVED FUNCTIONS LOST
Muscles of UL and LL Shoulder abduction, hip extension knee
extension and flexion plantar flexion
Holding objects firmly
Neck muscles Neck extension and flexion
Truncal muscles Difficulty in getting up from lying position
Esophageal muscle dysphagia

41. PROVISIONAL DIAGNOSIS
Nueurological- LMN quadriparesis along with neck and
truncal muscle weakness
Anatomical - muscle
Pathology- inflammatory
Etiology-may be idiopathic
Idiopathic inflammatory myopathy ? POLYMYOSITIS

42. DIFFERENTIAL DIAGNOSIS
•Dermatomyositis
•LGMD
•MND
•Myasthenia gravis(limb girdle type)
•Mitochondrial myopathy

43. DIFFERENTIAL DIAGNOSIS Points in Favor Points against
dermatomyositis Proximal symmetric
weakness
Myalgia
No skin manifestation
LGMD Proximal muscle weakness Distal weakness
Age 22(usually LGMD seen
in 1st
decade
MND Weakness and atrophy Weakness> atrophy
No fasciculation
Myasthenia gravis(limb
girdle type)
Weakness of proximal
upper limb and lower limb
No fatiguability
No diurnal variation
Mitochondrial myopathy Female patient
Weakness due to
myopathy
No maternal history
No EOM involvement

44. INVESTIGATIONS
➢ Haemoglobin: 11.2 gm%
➢ TLC: 8010/ cmm
➢ Neutrophil: 59%
➢ Lymphocyte: 31%
➢ Eosinophil: 2%
➢ Monocyte 8%
➢ TPC 2.74 lakh/ cmm
➢ ESR: 50 mm in 1st
hr
➢ CRP(Q)- 20 mg/dl
➢ Urine (Routine/Microscopy)
●Albumin: Nil
●Sugar: Nil
●RBC: 2-4/µl
●Pus Cell: 1-3/HPF
●Epithelial Cell: 2-4/HPF

45. INVESTIGATIONS
➢Serum Urea: 46 mg/dL
➢Serum Creatinine: 1.3 mg/dL
➢Serum Sodium: 137 meq/l
➢Serum Potassium 3.2 meq/l
➢HBsAg: Negative
➢HCV : Negative
➢HIV: Negative
DCT,ICT-negative
TSH-1.49 mIU/ml
ANA Profile- negative
Se Creatine kinase-4086(<145)
Sr Bilirubin total- 0.6mg/dl
Sr Bilirubin direct-0.2mg/dl
AST-165IU/L
ALT-124 IU/L
ALP-361 IU/L
Serum Protein- 6.2gm/dl
Serum Albumin- 3.3 gm/dl
Serum calcium- 1.1 mmol/L
LDH-2020 mg/dl

47. NCS-decrease CMAP in
bilateral median nerve
EMG-short duration, low
amplitude
Polyphasic MUAP with
complete recruitment seen in
right deltoid and right vastus
medialis
IMPRESSION-Above EDx study
s/o- motor axonal neuropathy
of bilateral median nerve and
MYOPATHIC pattern

51. FINAL DIAGNOSIS
Subacute pure motor LMN quadriparesis involving truncal,neck
and esophageal muscles without any skin lesions suggestive of
IDIOPATHIC INFLAMMATORY MYOPATHY- ?POLYMYOSITIS
(biopsy reported awaited)

52. THANK YOU