CNS CASE 2

PRESENTORS: MODERATORS:
DR. AYISHA ZAINAB
PROF: S.BALASUBRAMANIAN
DR. DELVINA V
PROF: DEVASENA
SRINIVASAN
Patient details:

52 years old female residing in a village near nagai district who has
completed her primary school education (upto 5th standard).
Homemaker who also does cattle rearing .
Chief complaints:
• Weakness of right lower limb since 2 years
• Weakness of left lower limb since 1 year
• Weakness of right upper limb since 8 months
• Change in voice since past 3 months
HISTORY OF PRESENT ILLNESS
• Patient was apparently asymptomatic until 2 years ago after which patient
developed weakness of the right lower limb which was insidious in onset .Initially
patient noticed stiffness of right lower limb with tripping of toes and inability to
grip on to slippers in the right foot. She was not able to run while rearing cattle.
However patient continued to go for cattle rearing and walked with the support
of the left lower limb. Patient also has occasional buckling of knee in the right
lower limb while walking since past 1 year. Since past one year she started
noticing weakness of left lower limb also (R>L) as walking became more difficult
for the past 1 year . Patient slowly stopped going for cattle rearing and was doing
only household work like cooking and used to leave the house with the help of
wooden stick to walk. The weakness progressed and patient also started
mobilizing at home using the support of wall since past 6 months. Patient started
having difficulty in getting up from squatting position and hence stopped using
Indian closet since past 3 months.
• Patient also had noticed that she was not able to lift her 1 year old grand-
daughter since 8 months. Patient was able to hold the knife but was
unable to give force to cut vegetables since past 5 months hence stopped
cooking. Patient was also unable to lift a mug of water using her right
upper limb but was able to do so without difficulty in the left upper limb.
• Patient was able to comb her hair, tie her saree , mix food and take it to
mouth without dropping or smearing over the face.
• Patient also noticed twitching of muscles in the right lower limb since 1
year and right hand since 1 month which was intermittent ,lasting for few
seconds and did not observe any specific aggravating or relieving factors
• Patient also had a change in her voice in the form of decreased volume
and slurring of speech with a nasal twang since past 3 months.
• Patient also gives history of occasional nasal regurgitation of food
(liquids >solids)since past 3 months and inability to cough since past 1
month. She had no difficulty in chewing food , making a bolus ,moving
tongue side to side and had no difficulty swallowing both solid and
liquid diet.
• Patient was able to lift the head from pillow without difficulty but was
unable to get up from bed and turn side to side in bed without support
since past 1 month. No complaints of breathlessness present.
SENSORY HISTORY
• She had no history of tingling, pain or burning sensation over upper or lower
limbs.
• She had no history of numbness or sensory loss over upper and lower limbs.
• She was able to appreciate cold and warm water when given a shower.
• She was able to feel clothes over the body and feel the firmness of the ground.
• She was able to feel vibration of her cell phone and could feel mosquito bite.
• She had difficulty walking in the dark since past 6 months as she needs the
support of the wall while walking .
 HMF & CRANIAL NERVE HISTORY
No history of memory disturbance or emotional lability
Able to smell her food.
Able to read sign boards without difficulty.
Patient had no history suggestive of drooping of eyelids or double vision
Able to appreciate hot and cold water while washing her face.
Patient had no history suggestive of difficulty in closing eyes while sleeping, drooling of saliva, deviation of angle of
mouth or loss of taste sensation.
Patient had no history suggestive of tinnitus, rotatory dizziness or difficulty in hearing.
Able to swallow liquids and solids without difficulty but has occasional regurgitation.
Able to lift her head from the pillow and turn it from side to side.
Patient had no history suggestive of difficulty in eating food and in moving her tongue freely inside the mouth.
CEREBELLAR HISTORY
• No history of swaying while sitting .
• No history of tremors in the upper and lower limbs.
• Patient gives history of difficulty walking through narrow passages and
swaying towards right while walking.
AUTONOMIC
• She is able to feel bladder fullness, able to control till a socially
acceptable situation, able to initiate micturition and able to
completely void.
• No history of bowel incontinence.
• No history of palpitations or abnormal sweating.
• No history of postural giddiness.
• Meningeal: No history of neck stiffness, fever, headache, seizure or
photophobia
• Antecedent: No history of trauma, loss of weight, recent vaccination,
exposure to pesticides, chemicals or heavy metals.
• Past history: known hypertensive since 1 month (on med tab
amlodipine 5mg od since 1 month)
Not a known diabetic/asthmatic/epilepsy/TB
• Personal : Mixed diet / regular bowel and bladder habits/no
addictions/ no loss of appetite or sleep disturbances present
FAMILY HISTORY
• Born out of a non consanguineous marriage.
• Delivery history – normal vaginal delivery.
• Developmental history – no delay in milestones.
TREATMENT HISTORY
• Patient had multiple visits to clinics for her complaints and was
advised vitamin B12 injection , analgesics and oral vitamin
supplements. In one of her visits to a PHC, patient was advised for a
CT brain in suspicion of cerebrovascular accident which was normal.
HISTORY SUMMARY
• 52 year old female , recently diagnosed hypertensive on treatment
has presented with asymmetrical progressive weakness of both lower
limb (R>L) and right upper limb, lower limb distal initially and then
progressed proximally, Right upper limb involving the proximal
muscles and trunk weakness since past 2 years . The weakness is
associated with twitching of right upper and right lower limb with
speech difficulty and nasal regurgitation. No positive family history.

• There is no history suggestive of sensory, higher mental function,

cerebellar or autonomic involvement.
• UMN and LMN type of weakness of both upper and lower limb with
9th and 10th cranial nerve involvement due to progressive degenerative
anterior horn cell disease probably secondary to Motor Neuron
Disease.
General examination:

Conscious, oriented. Was a right handed individual.

• BMI – 17.6 kg/m2
• No pallor, icterus, clubbing, cyanosis, lymphadenopathy, pedal edema.
• No neurocutaneous markers.
• No peripheral nerve thickening.
• Tattoo over her right forearm present
• PR- 88 /Minute, regular in rate, rhythm, normal volume, no
specific character, no vessel wall thickening, no radioradial or
radiofemoral delay.

• BP – 120/80mmHg, measured in the right upper limb in supine

position ( on standing 120 / 74 mmhg )

• RR – 16/Minute , regular , thoraco abdominal

• Single Breath Count – 24

Higher mental function:
• Conscious and well oriented to time, place and person
• Memory- Immediate, Recent and Remote intact
Verbal output: Normal
• Speech:
Fluency: Intact
Articulation: Guttural dysarthria +
Comprehension: Intact
Repetition: Intact
Reading: Intact
Naming: Intact
Writing: Intact
Nasal twang +
Hypophonia +

• MMSE: 28/30
• No emotional lability.
Cranial nerve Right Left Cranial nerve Right Left
VII-
I- N N Motor:
perceive smell of coffee wrinkling of forehead N N
Closing of eyes N N
Nasolabial fold N N
II- Puffing of cheeks N N
visual acuity (Snellen’s) 6/6 6/6 Angle of mouth N N
Visual field (confrontation) N N Sensory:
Color vision N N Taste over ant 2/3rd of tongue N N
Fundus N N Sensation over tragus N N
III, IV, VI- Secretomotor:
Ptosis No No Moistness of eyes and tongue N N
Squint No No
Extraocular movements Full&free Full&free
Pupil size 3mm 3mm VIII-
Light reflex(direct, indirect) + + Rinne’s Test AC>BC AC>BC
Accommodation + + Webers No lateralization
Smooth pursuit Normal Normal
Saccades Normal Normal IX, X-
Uvula Deviated to right
Gag reflex Absent Absent
Palatal movements Decreased Decreased
V- Intact Intact
Sensory: over opthalmic, maxillary and mandibular
divisions Normal Normal XI-
Motor- temporalis, messeter and pterygoids + + Trapezius and Sternocleidomastoid N N
Reflex- corneal, conjunctival, jaw jerk
XII-
Tongue- Bulk,Tone N N
Fasciculation Present Present
Power and tongue protrusion Reduced Reduced
Motor system:
• Attitude:
Patient in supine position
B/L ULs on the side of the body, supinated.
B/L LL extended at the knee joint, left leg ankle neutral position , right
left ankle plantar flexed and externally rotated.
B/L calf and thigh muscle wasting+
Small muscles of hand wasting+ R>L
Fasciculations over right arm and thigh +
Bulk Right (in cm) Left (in cm)

10cm above olecranon 22 23

10 cm below olecranon 16 16

18 cm above tibial tuberosity 34 34

10 cm below tibial tuberosity 24.5 25

Tone Right Left

Upper limb normal normal

Lower limb spastic normal

 POWER: Upper limbs Right Left

Shoulder
Abduction
15 3/5 4/5
15-90 3/5 3/5
>90 3/5 3/5
Adduction 4/5 4/5
Flexion 4/5 4/5
Extension 4/5 4/5
Int. Rotation 4/5 4/5
Ext. Rotation 4/5 4/5
Elbow
Flexion 4/5 4/5
Extension 4/5 4/5
Wrist
Flexion 3/5 3/5
Extension 3/5 3/5
Hand grip 90% 100%
 Name of the muscle Right Left Action

1. Opponens Pollicis Good Good Abduction of the thumb in the same

plane

2. Abductor Pollicis Brevis Good Good Palmar abduction of thumb

3. Flexor Pollicis Brevis Good Good Flexion of distal phalanx of thumb

4. Abductor Digiti Minimi Good Good Abduction of little finger

5. Flexor Digitorum Minimi Brevis Good Good Flexion of MCP of little fingers

6. Opponens Digiti Minimi Good Good Flexion and lateral rotation of the
little finger

7. Lumbricals Able to perform Able to perform Extension of interphalangeal joints,

flexion of metacarpophalangeal
joints.

8. Dorsal Interossei weak Good Abduction of index, ring & little fingers
away from midline of middle finger

9 Palmar Interossei: Good Good Adduction of index, ring and little

fingers toward middle finger
Lower limb Right Left

Hip Flexion 1/5 3/5

Extension 1/5 2/5

Adduction 2/5 4/5

Abduction 2/5 4/5

Int. Rotation 1/5 4/5

Ext. Rotation 1/5 4/5

Knee Flexion 1/5 4/5

Extension 2/5 4/5

1/5 4/5
Ankle Dorsi flexion

1/5 4/5
Plantar flexion
Superficial reflexes Right Left DTR Right Left

Corneal + + Biceps 2+ 2+

Triceps 2+ 2+
Conjunctival + +

Brachioradialis 2+ 2+
Jaw jerk normal
Knee 3+ 3+
Abdominal - +
Ankle 2+ 2+
Anal present
Clonus- - -
Ankle/patellar
Plantar extensor extensor
 Right(all dermatomes) Left(all dermatomes)

Crude Touch Normal Normal

Pain Normal Normal
Temperature Normal Normal

Fine touch Normal Normal

Vibration Normal Normal
Joint position Normal Normal

Cortical:
Tactile localisation Normal Normal
Two point discrimination Normal Normal
Graphaesthesia Normal Normal
Stereognosis Normal Normal
Cerebellum

Titubation -
Nystagmus No
Rebound phenomenon No
Dysdiadokokinesia No
Finger finger test Able to perform
Finger nose test Able to perform
Heel knee test Cannot be checked in right / left- Able to
perform

Pendular knee jerk No

Tandem walking Could not be assesed
Truncal / stance ataxia no
AUTONOMIC NERVOUS SYSTEM
• Postural hypotension - absent

• Abnormal sweating – absent

• Resting tachycardia – absent

GAIT

• Normal stance

• Not able to walk without support

• Right Circumduction gait

• Able to stop

• Able to turn around

• Arm swing is present

• Meningeal signs- Kernig's and Brudzinski negative
• Spine and Cranium- Normal

OTHER SYSTEMS:
• CVS- S1 S2 +
• RS- B/LAE+, clear, no added sounds
• P/A- soft, BS+
Diagnosis:
• Progressive quadriparesis with bulbar involvement (9,10,12 – LMN )
with no HMF/Sensory/Cerebellar/Autonomic involvement
• Structures involved – Corticospinal tract, Anterior horn cell, and
nucleus of 9, 10, 12 cranial nerve
• Etiology- Degenerative
• MND- ALS with Bulbar incolvement.