Mr.

Shankar Ganesh, 55 year old male patient from madurai , studied up to

5th std, Rt handed individual whose reliability of information is fair has come
with

c/o back pain for the past 6 months

c/o difficulty in using all 4 limbs for 20 days

c/o numbness in both legs for 1 month

HOPI

 Patient was apparently normal 6 months back ,when he developed

back pain, radiating to left lower limb which was insidious in onset,
gradually progressive, dull aching, localised, aggravated by movements,
and got received by medications.
 In the past 30 days patient developed stiff weakness of left Lower limb in
the form of difficulty in holding slippers, tripping of toes, buckling of
knees,
 No h/o in the form of difficulty in holding objects, difficulty in mixing
food, difficulty in buttoning and unbuttoning shirts
 No h/o difficulty in combing hairs
 No h/o difficulty in reaching for overhead objects
 In another few days patient developed similar type of stiff weakness in
right lower limb
 No H/o difficulty in using the left upper limbs in the form of
difficulty in buttoning /unbuttoning shirts
difficulty in mixing foods /take food to mouth
difficulty in reaching for overhead objects.
 No H/o difficulty in rolling over bed,getting up from bed,lifting head up
while lying down.
 H/o numbness and decreased sensation of insect bite, hot and cold
sensation while bathing and decreased sensation of clothes in left lower
limb for past 30 days
 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 decreased sense of smell.

 No h/o diminished vision,defective colour vision.

 No h/o dipopia/ptosis/squint.

 No h/o decrease sensation over face/difficulty in chewing.

 No h/o difficulty in frowning forehead/raising eyebrows/puffing of

cheeks/deviation of angle of mouth while smiling /drooling of saliva.

 No H/o hard of hearing/tinnitus.

 No h/o dysphagia/nasal regurgitation/hoarseness of voice/stridor.

 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 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,postural giddiness

  No h/o cough with expectoration/fever.

 No h/o trauma.

 No h/o loss of weight/appetite.

 No h/o neck stiffness.

 No h/o dog bite /recent vaccination.

PAST H/O

known T2DM/HT/heart disease on regular treatment since 5 years. Not

K/c/o TB/Asthmatic /epileptic.

PERSONAL H/O

Not tobacco chewer/alcoholic.takes mixed diet.

FAMILY H/O

No h/o similar illness in the family.

Summary

55 year old male with insidious onset gradually progressing back pain with
radiation to left lower limb with sensory loss below L4 dermatomes with no
bowel,bladder involvement ,no autonomic symptoms ,no cerebellar
involvement or involuntary movements.

O/E

Patient conscious
oriented
not anaemic
not jaundiced
bp-130/80 mm Hg no cyanosis
Lt UL sitting No clubbing
 posture no pedal edema/gen. lymphadenopathy
no neck rigidity/neurocutaneous markers

tenderness + in cervical spine region

no Low hair line , Short neck

neck movements –painful not restricted.

MMSE score
oriented to time ,place -8/10
registration -3/3 26/30
recall -3/3
attention and calculation -5/5
language -7/9

Cranial nerve examination

olfactory nerve normal normal

Optic nerve visual acuity 20/100 20/70

Field of vision Normal Normal
Colour vision Normal Normal
Fundus Normal Normal

EOM full EOM full

Oculomotor ,trochlear and abducent nerve No No
ptosis/squin ptosis/squint
t
Ophthalmic Normal Normal
Trigeminal nerve maxillary Normal Normal
Mandibular Normal Normal
Motor Normal Normal
Jaw jerk Absent Absent
Frowning forehead Normal Normal
Facial nerve raising eyebrows Normal Normal
Puffing cheeks Normal Normal
Angle of mouth No deviation No deviation
 Rinnes test AC>BC AC>BC
Vestibulocochlear nerve webers test No No
lateralization lateralization
ABC normal normal
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 33 cms 33cms

Forearm 20 cms 20 cms
Thigh 45 cms 45 cms
Leg 28 cms 28 cms

Tone right left

Upper limb NORMAL NORMAL

Lower limb NORMAL NORMAL

Power right left

Shoulder flexion
extension 5/5 5/5
 abduction
adduction
Elbow flexion 5/5 5/5
Extension 5/5 5/5
Wrist flexion 5/5 5/5
Extension
Hand grip 100% 100%
Hip flexion
extension 5/5 5/5
abduction
adduction
Knee flexion 4+/5 4/5
Extension 4+/5 4/5
Ankle dorsiflexion 3/5 3/5
Plantar flexion
SLRT Negetive Positive

Reflexes Right left

Biceps 2+ 2+
Supinator 2+ 2+
Triceps 2+ 2+
Knee 2+ 2+
Ankle 3+ 3+

Corneal Present Present

Conjuctival Present Present
Abdominal Present Present

Sensory disturbances below L4 level

Coordination
Finger nose test Normal Normal
Finger finger nose test Normal Normal
Heel knee test Normal normal

No involuntary movements .

55 year old male with insidious onset gradually progressing back pain with
radiation to left lower limb with sensory loss below L4 dermatomes with no
bowel,bladder involvement ,no autonomic symptoms ,no cerebellar
involvement or involuntary movements.

P/O Lumbar degenerative disc disease with radiculopathy.