Mr.

Ganesan, 54 year old male patient, studied up to 5th std, blacksmith by

occupation , Rt handed individual whose reliability of information is fair has come
with

c/o Ringing sound in right ear for 2yrs

Hard of hearing for 2 yrs

Swaying to right side for 10 month

Headache for 10months

HOPI

 Patient was apparently normal 2 yrs back when patient developed ringing
sensation in the right ear, insidious onset, gradually progressing, initially
intermittent and later continuous , non pulsatile in nature, and often
disturbed his sleep, at present patient does not have any such complaints
 Later patient developed hard of hearing in the right ear in the form of
difficulty in using mobile phone with right ear, but found to hear better
when he change the mobile to right ear
 No h/o ear discharge from the right ear
 No h/o any trauma
 No h/o better hearing in noisy environment
 No h/o Exaggerated perception of sound on increasing TV volume
 No h/o similar complaints in the left ear
 No h/o vertigo, giddiness, nausea or vomiting.
 In the past ten months patient noticed swaying to right side while walking
 For the past 10 months patient developed Headache which was holocrainal
in nature, thrombing type, frequently associated with vomiting,
 No h/o seizures
 No h/o memory disturbances
 No h/o difficulty in identifying persons and way finding difficulty
 No h/o difficulty n handling money
 No h/o decreased sense of smell.
 No h/o dipopia/ drooping of eyelids
 No h/o decrease sensation over face/difficulty in chewing.
 No H/o difficulty in puffing of cheeks
 No H/o difficulty in closing the right eye
 No H/o difficulty in frowning forehead in right side
 No H/o drooling of saliva form the angle of mouth
 No h/o taste disturbances
 No h/o dysphagia/nasal regurgitation/hoarseness of voice
 No h/o difficulty in shrugging shoulders or turning head side to side.
 No h/o deviation of tongue while protruding/difficulty in movements of
tongue.
 No h/o stiff / flail weakness of limbs
 Able to mix food/ button his shirts, comb his hairs, reach for overhead
objects , able to roll over bed, get up from bed without difficulty, able to
raise head form bed
 No h/o difficulty in squatting and getting up from sitting position
 No h/o buckling of knees or tripping of toes
 No h/o any sensory disturbances over the body and face
 No H/o numbness and decreased sensation of insect bite, hot and cold
sensation while bathing and decreased sensation of clothes
 No H/o cotton wool sensation while walking and unsteadiness while
washing face , electric shock like sensation while extending neck or
difficulty in walking during night.
 No H/o wasting ,twitching and fasciculations.
 No h/o cramps , involuntary movements.
 No h/o tremors , unsteadiness while sitting standing or walking,head
nodding.
 No h/o difficulty in initiating micturition/control the stream of
micturition /fully evacuate the bladder/ feeling of residual urine/increased
frequency of micturition.
 No h/o bowel impaction. No h/o difficulty in initiating defecation /fully
evacuate the bowel.
 No h/o abnormal sweating, palpitations
 No h/o cough with expectoration/fever.
  No h/o trauma.
 No h/o loss of weight/appetite.
 No h/o dog bite /recent vaccination.

PAST H/O – Not a k/c of Diabetes, HT Asthmatic, Epilepsy or CAD

Personal h/o – Takes mixed diet, smoker alcoholic for 10 yrs

Family h/o – No similar illness in the family

Summary :

54 yr old male patient presented with insidious onset gradually progressing

neurological illness in the form of right side SNHL associated with non pulsatile
tinnitus , suggestive of involvement of right Vesibulocochlear nerve, with right
cerebellar symptoms, and ICT type of headache with gradual painless visual loss
without higher mental function abnormality, without other cranial nerve
involvement , spinomotor involvement and autonomic system involvement

Structure involved – 8 th cr nerve followed, Cerebellum followed by 2 nd cranial

nerve

Possibility of right CP angle lesion

O/E

Patient conscious
oriented
not anaemic
not jaundiced bp-122/74 mm Hg
no cyanosis right UL sitting
No clubbing posture
 No pedal edema/gen. lymphadenopathy
No neck rigidity/neurocutaneous markers

Cranial nerve examination

olfactory nerve normal normal

Optic nerve visual acuity 6/60 6/60

Field of vision-

Colour vision Absent Absent

Fundus
Grey in colour, margins blurred,cup disc could not be
made out, surrounding disc sugg of secondary optic
atrophy

EOM full
Oculomotor ,trochlear and abducent nerve No
ptosis/squin
t
Ophthalmic Reduced Normal
Trigeminal nerve maxillary Reduced Normal
Mandibular Reduced Normal
Motor Normal Normal
Jaw jerk Absent Absent
Frowning forehead Normal Normal
Facial nerve Eye tight closure Normal Normal
Puffing cheeks Normal Normal
Angle of mouth
Lacrimation - Normal
Taste – Normal tested for
salt, sweet and sour

Rinnes test AC>BC AC>BC

V .C nerve webers test –left lateralized
 ABC reduced Normal
Fukuda – turns to right
Star walking – turns to right
Uvula Midline Midline
Glossopharyngeal Palatal movements Normal Normal
nerve and vagus nerve gag reflex Present Present

Shrugging shoulders Normal Normal

Spinal accessory nerve turning head side to side Normal Normal
Trapezius reflex Normal Normal

Hypoglossal nerve tongue movements Normal Normal

Protrusion No deviation No deviation

Examination of spinomotor system

Bulk Right Left

Arm 32cm 32cm

Forearm 22 cm 22 cm
Thigh 38 cm 38 cm
Leg 27cm 27 cm

Tone Right Left

Upper limb Normal Normal

Lower limb Normal Normal

Power Right Left

Shoulder flexion 5/5 ?

 extension 5/5 5 /5
abduction 5/5
adduction 5/5
Elbow flexion 5/5 5/5
Extension 5/5 5/5
Wrist flexion 5/5 5/5
Extension 5/5
Hand grip Good Good
Hip flexion
extension 5/5 5/5
abduction
adduction
Knee flexion 5/5 5/5
Extension 5/5 5/5
Ankle dorsiflexion 5/5 5/5
Plantar flexion

Reflexes Right Left

Trapezius Normal Normal
Biceps Normal Normal
Supinator Normal Normal
Triceps Normal Normal
Knee Normal Normal
Ankle Normal Normal

Superficial reflex

Corneal Present Present

Conjuctival Present Present
Abdominal Present Present
Plantar Flexor Flexor
Sensory system

Sensory system Right Left

Pain Normal Normal
Touch Normal Normal
Temperature Normal Normal
Joint sense Normal Normal
Vibration sense Normal Normal
Coordination

Finger nose test Impaired Normal

Finger finger nose test Impaired Normal
Heel knee test Impaired Normal

Tandem walking – Impaired, Dysdiadokinesia – Present on right side

Rhombergs - negative

No involuntary movements .

Summary :

54 yr old male patient presented with insidious onset gradually progressing

neurological illness in the form of right side SNHL associated with non pulsatile
tinnitus , suggestive of involvement of right Vesibulocochlear nerve, followed by
right trigeminal nerve, with right cerebellar symptoms, and ICT type of headache
with gradual painless visual loss without higher mental function abnormality,
without other cranial nerve involvement , spinomotor involvement and
autonomic system involvement

Structure involved – 8 th cranial nerve followed by 5th cranial nerve, Cerebellum

followed by 2 nd cranial nerve

Possibility of right CP angle lesion.