4. HISTORY OF PRESENT ILLNESS
• The condition has started 3 month ago by gradual onset progressive
course when the patient developed lower back pain which was localized
, throbbing (some times stabbing )moderate to sever ,increased with
cough ,sneezing and movement and became more sever at night ,
decreased slightly with rest and analgesia , radiating to both buttocks
• 1month later patient developed weakness in both lower limbs which was
left more than right , proximal more than distal , flexor equal extensor
associated with hypotonia completed within 1 month till patient became
wheelchair
5. 1.5 month from the onset of the condition the relevant noticed wasting
in both lower limbs especially the anterior aspect of the thigh
Patient also noticed worm like sensation at the anterior part of the thigh
at the beginning of weakness then disappeared nowadays
At the beginning of the weakness the patient has complained from
urine incontinence and lately became complaining from urine and stool
incontinence
6. • 3 weeks ago patient has complained from mid- dorsal localized pain
(carry the same character of lower back pain ) without increasing in
the previous weakness .
7. during period of the disease
Patient denied any associated fever or
significant weight loss all over the course of
disease
No history suggestive upper limbs affection
No history suggestive cranial nerve affection
No history suggestive cerebellar affection
No history suggestive trauma ,headache or
fits
No history of raw milk ingestion or contact to
animal
8. • Born and live in Giza
• Married
• Has 3 sibling the youngest is 29 y .o
• Smoker
• No other special habit of medical important
• Social history
9. PAST HISTORY
Diabetes uncontrolled for 25 year on oral treatment
Hypertensive
left head femur fraction (nail and screw fixation) 2 years ago
No history of blood transfusion
No history of trauma
No history of liver or kidney disease
No history of drug addiction .
11. FORMULATION
Male patient 71 year old diabetic uncontrolled and
hypertensive presented 3 months ago by gradual
onset progressive course of :
Lower back bony pain
Asymmetrical lower motor neuron weakness in both
lower limbs
urine and stool incontinence
Mid dorsal bony pain
13. • BP: 110/70
• Pulse: 84 beats/m, regular, average volume, equal on both sides.
• RR: 14 cycle/m.
• T: 37◦ C.
14. • 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 ascits or supra
pubic dullness.
• Skin : no rash, plaques only atrophic changes in both feet
16. MENTAL STATE
• The patient is fully conscious, attentive, well oriented to time, place,
person, with intact memory, depressed mood .
• MMSE : 25/30
18. 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
19. 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 .
20. 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.
21. MOTOR SYSTEM
Upper limbs :
Muscle state ,wasting and guttering in the small muscle of the hands
Power : full power
Reflexes;normal reflexes
22. Lower limbs
Inspection ; wasting in the medial and
anterior side of the thigh and anterior aspect
of the leg
Power ; left more than right proximal more
than distal , adduction more than abduction
, extensors more than flexors
24. 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
25. SENSORY SYSTEM
• Superficial: glove and HIGH stock hypothesia
• Hypothesia at saddle area
• Deep: VIBRATION SENSATION LOST ON MEDIAL MALLEOLUS and
preserved at tibial tuobersty
