67 YEAR OLD MALE WITH PROGRESSIVE SLOWNESS AND WEAKNESS OF LIMBS

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CHIEF COMPLAINTS

67 Year old male patient farmer by occupation was brought to the causality with 

C/o difficulty in breathing since 20 days

C/o cough with sputum since 20 days

C/o weakness since 20 days

HISTORY OF PRESENT ILLNESS

The patient was apparently asymptomatic 2 years ago, when he developed gradual slowness in movements, gait disturbances and frequent falls.

20 days ago he developed difficulty in breathing which was sudden in onset and progressed gradually from Grade I MMrC to Grade III MMrC, with no diurnal or seasonal variation and no relieving or aggravating factors.

It is also associated with cough, productive, copious amount , white in colours, turbid, thick in consistency , not blood stained and not foul smelling.

H/o sudden fall on his back since 2 years due to loss of postural control.

Falls not associated with any giddiness, vertigo, tiredness, slippage and he was conscious after the fall.

He was taken to a nearby hospital , where a CT scan of the brain was taken and the report showed no abnormalities.

Since the first episode 2 years ago he started developing slowness in all his movements, initially started with the head and neck and has now progressed downwards to affect the lower limbs.

There is no h/o of wasting, thinning of the upper and lower limb muscles

No h/o of difficulty in brushing teeth, buttoning shirts, wearing slippers, getting up from the chair or sitting or sleeping .

He had a history of a similar fall 20 days ago , since which he has developed difficulty in brushing teeth, buttoning shirts, wearing slippers, getting up from the chair, sitting or sleeping .

Movements of the limbs are extremely slow and are not effective in completing any work.

Limbs are stiff and hard

No wasting or thinning

Able to feel clothes, hot and cold sensations

No tingling or numbness reported 

No loss or alteration in the consciousness 

No speech disturbances.

No delusions, hallucinations, emotional disturbances 

No stiffness of neck , fever or vomitings

No h/o diarrhoea , abdominal pain 

No h/o palpitations, chest pain

No h/o seizures

PAST HISTORY

K/C/O TB (resolved) underwent treatment 20 years ago

N/K/C/O DM/CAD/CVA/EPILEPSY

K/C/O HTN since 1 year on regular medication

K/C/O Asthma since 6 months and on regular medication

PERSONAL HISTORY

Sleep adequate 

Bowel and Bladder - Regular

Appetite - Normal

Habits - Occasional Toddy Drinker

GENERAL EXAMINATION

The patient is conscious, coherent and cooperative

And well oriented to time, place and person

VITALS

Temp - 98.7 F

RR - 34 cpm

PR - 80 bpm

BP - 120/70 mmhg

Spo2 - 93 % on RA

No signs of Pallor, Icterus, Cyanosis, Clubbing or generalised lymphadenopathy

SYSTEMIC EXAMINATION 

CVS - S1 S2 Heard, No Murmurs

RS - BAE +

PA - Soft / Non Tender

CNS Examination

The Patient is conscious

Higher Mental Status

Immediate - Intact

Implied - Intact

Long - Intact

GCS - E4V5M6

Right Handed

Neck Rigidity - 

Brudzinsky - Negative

Kernig - Negative 

Cranial Nerves

1 - intact

2 - intact

3 ,4,6 - Unable to ellicit

5 - Intact

7 - intact

8 - intact

9 - Intact 

10 - intact

11 - intact 

12 - intact

Joint Position - Intact in both limbs

Stereognosis - Intact in both limbs

Tremors - Intentional, sometimes resting

MOTOR SYSTEM

	Right	Left
Bulk	Normal	Decreased
Tone	Hypertonic	Hypertonic
Power	4/5	4/5

Reflexes

	Right	Left
Biceps	+	+
Triceps	+	+
Knee	+	+
Ankle	+	+
Plantar	Flexion	Flexion

OTHER FINDINGS

Slow Occular Saccades +

Gaze Palsy +

Masked Facies +

Serpentine Stare +

Hypophonia +

Bradykinesia +

Rigidity +

Myerson Sign +

CLINICAL IMAGES

INVESTIGATIONS

MICKEY MOUSE SIGN - MIDBRAIN MRI TRANSVERSE SECTION

HUMMING BIRD SIGN - MRI SAGGITAL SECTION

PROVISIONAL DIAGNOSIS

PROGRESSIVE SUPRANUCLEAR PALSY (ATYPICAL PARKINSONISM) 

[PARKINSON PLUS]

TREATMENT

1. INJ PIPTAZ 2.25 GM IV QID

2.INJ CLINDAMYCIN 600 MG IV BD

3. INJ METROGYL 500 MG IV TID

4.TAB SYNDOPA PLUS 125 MG RT QID

5. TAB ECOSPRIN 75 MG RT OD

6. TAB ATORVASTATIN 40 MG RT HS

7. TAB DOLO 650 MG RT TID

8.SYP GRILLINCTUS 15 ML RT TID