THE WHITE ARMY

CLINICAL CASE PRESENTATION

MODERATOR : Dr.SR Chandra
Retd Prof, NIMHANS
GENERAL DETAILS
NAME : Mrs.XYZ
AGE : 65
GENDER : Female
OCCUPATION : Retd Staff Nurse
ADDRESS : Malur
INFORMANT : Self , daughter - reliable
CHIEF COMPLAINTS
• Difficulty in using objects since 3 years.
HISTORY OF PRESENTING ILLNESS
Pre-morbid : Patient wakes up at 6 am , prepares breakfast,
goes to hospital by 7 am , comes back by 3 pm , prepares
lunch & eats, sleeps for 1-2 hours, goes to temple ,prepares
dinner by 8pm and sleeps by 10pm.

In-Hospital : attends rounds, prepares duty roster, indents

medications, supervises work.
• Patient was apparently normal till 3 years ago,
performing her daily activities when she initially
noticed difficulty in putting the badge on her
dress.She was able to identify the badge, hold it
tightly, insert pin into the dress but difficulty in
pinning , unpinning and stopped wearing the badge.
• Difficulty in knotting, unknotting petticoat and
occasionally used scissor to remove the knot
• She was able to make pleats symmetrically, now asks
for daughter for assistance in wearing saree
frequently , stopped wearing saree due to difficulty in
wearing and is been wearing gown since 2 years
• Difficulty in putting paste over the brush-Squeezes excess
amount of paste, brushes only front part of the teeth
,doesn’t manipulate the brush to the sides.
• Difficulty in opening and closing jar lid, holds it tightly and
keeps moving the lid clockwise and anticlockwise
clumpsily.
• Difficulty in opening the pen cap, with change in pattern
of holding pen cap ,initially used to hold with 2 fingers,
now uses all the fingers and posteriorly
• Difficulty in lighting match stick ,identifies it, but strikes
the matchstick clumpsily, unable to light the matchstick
and stopped lighting lamp at home since 2 years
• Over the next 1 month, developed difficulty in writing,
initially noted while writing a letter, knows what
content to write, identifies the pen, hold it tight,
places on paper however while attempting to write
she could write only the first few words however
noticed different shape of writing and started
dictating the letter to her colleague.
• Rejection of multiple cheques due to changes in
signature.
• Difficulty in cooking chapatti, with change in shapes
due to difficulty manipulating the stick over the dough
• No cooking error.No excess/reduced ingredients
• Difficulty drinking from straw with mild spillage from
angle of mouth and stopped using straw since 1 year.
-No h/o difficulty chewing, swallowing, dysarthria,
nasal regurgitation, choking.
• Disturbed sleep – increased sleep latency – initially 5
min , now 1-2 hours.No nocturnal awakening,
excessive day time sleepiness, snoring.
• h/o 11kg weight loss with reduced appetite since 2
years.
-No h/o early satiety, palpiations, sweating, heat or
cold intolerance, visual disturbances, osmotic
symptoms
• No h/o disinhibition, emotional incontinence, personality
changes, anger outburst, obsessions, hallucinations, food
faddism,
• No memory disturbance, difficulty naming objects,
recognizing faces, grammatical mistakes
• No calculation errors.
• No h/o inappropriate use of objects
• No h/o weakness/stiffness/wasting of limbs, sensory loss,
bowel bladder incontinence
• No involuntary movements
• No h.o hallucination /fluctuation of symptoms
• No h/s/o alien limb phenomenon
PAST HISTORY
• HTN since 5 years on amlodipine 5mg OD
• No previous admissions to the hospital.
PERSONAL HISTORY
• Predominant vegetarian diet
• Appetite – reduced
• Bowel and bladder – regular
• Sleep – increased latency
FAMILY HISTORY
• No family history of similar complaints
• No h/o neurodegenerative diseases
SUMMARY
A 65 year lady presented with progressive difficulty in using
various objects since 3 years with significant weight loss

Neurodeficit : Limb apraxia, ?oro-buccal apraxia

Anatomical localization : Left parietal lobe, frontal lobe
Pathology : 1.Degenerative 2.Paraneoplastic
GENERAL EXAMINATION
Elderly female , conscious, cooperative , lying supine on the
bed, well oriented to time place person.
Conjuctival pallor present
No cyanosis, clubbing lymphadenopathy edema
BMI – 18kg/m2

BP : 140/80mmHg Right ,Left arm supine posture

PR : 78 /min regular normal volume, character, peripheral
pulses were well felt with no radial/femoral delays
RR : 18 cpm thoracoabdominal
NERVOUS SYSTEM EXAMINATION
• HIGHER MENTAL FUNCTIONS
• Conscious, oriented to time , place person.
• Handedness – Right.
• Attention –Digit forward -5
Vigilance –commission -4, omission -3
• Working memory –Digit backward -3 , Serial subtraction (
100-7)- 93, 86
• Language
1. Spontaneous speech - fluency , grammar : normal
No paraphasia, neologism, perseveration, circumloculation
2. Comprehension – normal
3. Naming – normal
4. Reading – normal
5. Repetition – words, sentences – normal
6. Writing – Spontaneous, dictation, copying – not able to
perform
• Memory :
1. Recent – 7 word address recall : 0 min -6, 20min -3
2. Remote – normal
3. Visual memory – 5 hidden objects : normal
• Parietal
1. Visuospatial , constructional apraxia
Clock drawing, copying figures – not done.
2. Hemineglect : Line bisection : normal
3. Dressing apraxia : had difficulty
• Praxis :
1. Imitation of gesture :not done
2. Gesture knowledge : present
3. Sequence of action : cant be done
4. Conceptual knowledge : present
5. Real object use : present
• Finger anomia – present
• Acalculia – cant do
able to identify numbers and arrhythmic symbols
• Agraphia – present( unable to write on paper/air, hold pen)
• Right /left confusion : Identification on self – done
Identification on examiner – impaired.
• Graphesthesia – lost
• Tactile localization – lose
• 2 point discrimination – cant do
• FRONTAL
1. Similarities normal
2. First edge palm – not able to as not imitating gestures
3. Perseveration present.
4. Proverb interpretation – normal
5. Judgement – normal.
• OCCIPITAL
1. Visual field – normal
2. No isual agnosia
3. Color naming normal
4. No simultanognosia
5. Letter cancellation – normal.
CRANIAL NERVE RIGHT
I Normal
II Visual acuity : Normal
Visual field : normal
No visual inattention/sensory
extinction
Pupil : Round reactive 4mm in size
Color vision : Normal
Fundus : fundal glow present
III,IV,VI Pupillary reflexes: present
EOM – Normal and full range
V Sensory :Intact
Motor:Intact
Jaw Jerk :Absent
LEFT
Normal
Visual acuity: Normal
Visual field: Normal
No visual inattention/sensory
extinction
Pupil : Round reactive 4mm in size
Color vision : Normal
Fundus :Fundal glow present
Pupillary reflex : present
EOM – normal and full range
Sensory :Intact
Motor:Intact
Jaw Jerk :Absent
CRANIAL NERVE LEFT RIGHT
VII Normal Normal

VIII Normal by ticking watch Normal by ticking watch

test test
IX,X Palatal movements Palatal movements
present present

XI Normal power of Normal power of

sternocleidomastoid and sternocleidomastoid and
trapezius trapezius
XII No deviation on No deviation on
protrusion; No atrophy, protrusion; No atrophy,
fasciculation fasciculation
MOTOR SYSTEM
PARAMETER LEFT[CM] RIGHT[CM]
Arm circumference 17 17
Forearm 14 14
Thigh 25 25
Calf 20 20
TONE
PARAMETER LEFT RIGHT
Upper limb
I. Flexor Normal Normal
II. Extensor Normal Normal
Lower Limb
I. Flexor Normal Normal
II. Extensor Normal Normal
POWER
Parameter LEFT RIGHT
1.Movement at shoulder
joint 5 5
• Flexion 5 5
• Extension 5 5
• Abduction 5 5
• Adduction 5 5
• Internal rotation 5 5
• External rotation

2.Movement at elbow
joint
• Flexion 5 5
• Extension 5 5
Parameter LEFT RIGHT
3.Movement at Wrist joint
• Flexion 5 5
• Extension 5 5
• Abduction 5 5
• Adduction 5 5

4.Movement at Hip Joint

• Flexion 5 5
• Extension 5 5
• Abduction 5 5
• Adduction 5 5
• External Rotation 5 5
• Internal Rotation 5 5
Parameter LEFT RIGHT
5.Movement at Knee Joint

• Flexion 5 5
• Extension 5 5

6. Movement at Ankle Joint

• Plantar Flexion 5 5
• Dorsiflexion 5 5

7. Toe Movements

• Flexion 5 5
• Extension 5 5
Parameter LEFT RIGHT
Superficial reflexes
1. Corneal Present Present
2. Conjunctival Present Present
3. Abdominal Present Present
4. Plantar Flexor Flexor

Deep Tendon Reflexes

1. Biceps 2+ 2+
2. Triceps 2+ 2+
3. Supinator 2+ 2+
4. Knee 3+ 3+
5. Ankle 3+ 3+
CO-ORDINATION
LEFT RIGHT
Upper Limb Normal Normal
Lower Limb Normal Normal

• INVOLUNTARY MOVEMENTS : None

SENSORY SYSTEM
PARAMETER LEFT RIGHT
Spinothalamic
Sensations Intact Intact
1. Pain Intact Intact
2. Temperature Intact Intact
3. Pressure
Posterior Column
Sensations Intact Intact
1. Fine touch Intact Intact
2. Vibration Intact Intact
3. Proprioception
CEREBELLUM EXAMINATION
• 1.Titubation: Absent
• 2.Nystagmus: Absent
• 3.Scanning speech: absent
• 4.Dysmetria/Past pointing: absent
• 5.Dysdiadochokinesia: normal
• 6.Intention tremor: Absent
• 7.Rebound phenomenon: Absent
• 8.Pendular knee jerk: Absent
• No signs of cerebellar dysfunction present
No signs of meningeal Irritation
Gait:Normal
Skull spine carotids- normal
OTHER SYSTEM EXAMINATION
Cardiovascular Examination :
S1S2 heard normally all areas. Normal S2 split.
No added sounds /murmurs.

Respiratory Examination:
Chest movements equal bilaterally
Normal vescicular breath sounds all areas
No added sounds
Per abdomen examination:
Soft non tender abdomen
no palpable organomegaly
FINAL DIAGNOSIS
• Functional deficit : Graphesthesia, dressing apraxia,
gerstmann
• Anatomical localization : Biparietal, frontal
• Pathology- Degenerative
• DDx : Biparietal variant of PCA of Alzheimers disease
• CBD- No asymmetry/parkinonism