Clinical Case - Neurology

CASE

Mr. P 60 year old male, admitted with the presenting complaints of


+Difficulty in using both upper and lower limbs -3 month
+Recurrent falls - 3 month
+Altered behaviour - 40 days
+Urinary/faecal incontinence - 25 days

Pt was apparently normal 3 months back, when he started developing difficulty in using both lower limbs in the form of tightness of joints, slowness of movements, difficulty in initiating a movement, which was insidious in onset and gradually progressive
Difficulty in getting up from squatting position, climbing stairs
Difficulty in walking/slowness of walking/H/o falls
No h/o tripping of toes/difficulty in holding slippers
No H/o difficulty in using upper limb
H/o generalized slowing of activity
H/o memory disturbances
h/o poor attention
No h/o LOC/Seizures/Vomitting/hallucinations
H/o altered behaviour on/off for the past 40 days
H/o emotional instabilty is present
No h/o swaying towards any particular side/bringing food to mouth
No h/o any cranial nerve involvement
No h/o any sensory disturbances
No h/o any involunatary movements
H/o urinary/bowel incontinence present
No h/o trauma/fever/ENT bleeding
No other specific complaints

PAST HISTORY:

H/o seizures 4 years back for which he is on regular treatment. No further episodes
Not a known DM/SHT/CVA/PT/Any similar illness
PERSONAL HISTORY:
Smoker/alcoholic/mixed diet

General examination

Pt. conscious, not oriented completely, afebrile, hydration fair
No Pa/Cy/Cl/PE/La/JVP/Ict/Rashes
PR-72/min, BP-140/90 mm Hg
CVS/RS/PA-wnl
CNS

Higher functions
Conscious (MMSE 18/30)
Not oriented completely
Poor attention
Speech normal
Memory poor
No hallucinations
Comprehension impaired
Cranial nerves-WNL

Spinomotor system
Bulk- equal on both sides
Tone- hypertonia/rigidity on UL/LL both sides
Power- 4+/5 on both upper limbs
4/5 on both lower limbs
DTR-BJ,TJ,SJ- brisk on both sides
KJ,AJ- Exaggarated on both sides
Superficial- abdominal- absent
Plantar- extensor both sides
Gait- Hesitancy of gait, short steps, shuffling, wide based gait, turns en bloc

Cerebellar - normal except for the slowness of movements/performing tests
Extrapyrmidal- rigidity/bradykinesia present
Autonomic- bowel/bladder incontinence
Sensory system - normal,

Please use the comment section to contribute your diagnosis


MRI attached