name - hanumantappa

age - 60 yrs

sex - male

occupation - farmer

address - hirebelekere(DVG)

doa - 1/8/03

medicine 'd' unit, CGH

chief complaints:

dizziness and swaying - 3mths

history of present illness

the patient was apparently well 3 months back, when he suddenly felt dizzy while at home, 3 months ago. the onset of the dizziness was assosciated with a slight tingling sensation at the back of the head and a mild headache which was diffuse in location. the dizziness persisted and did not subside with rest. patient also noticed that he was swaying while walking, more towards the left side. as the dizzy sensation and swaying did not subside for 2-3 days, patient sought medical help in the form of native medicines which he consumed for the next fifteen days but found no relief, on the contrary the dizziness and swaying seemed to increase in severity. he then sought allopathic help, and he was administered some tablets and injections for a few days but still did not find any relief from the dizziness and swaying. this dizziness was persistent and there was no variation in the dizziness while travelling on a bus or in an auto, or with change in posture. however dizziness seemed to increase slightly when his eyes were closed, and early in the morning when he used to get up from bed to wash his face. during this period, pt's relatives noticed that he had infrequent blinking of the left eye. pt. also noticed that he had tremors in his left hand which appeared while trying to attempt any task such as picking up objects or while buttoning his shirt and which disappeared at rest. pt. also noticed some slurring of his speech and complained of difficulty in pronouncing/speaking words and sentences. pt. also felt that the hearing in his left ear had decreased slightly. his dizziness and swaying gradually increased in severity till he was unable to walk without support, and was unable to perform any tasks with his left hand due to increasing clumsiness. pt. was able to hold and grasp objects but was not able to execute tasks, for example picking up objects with his left hand and placing them on a particular spot or picking up a tumbler and bringing it to his mouth. it was then that he came to CGH for rx. throughout this period pt. c/o intermittent, mild, diffuse headaches which had no aggravating or relieving factors.

no h/o nausea/vomiting/tinnitus

no h/o syncopal attacks/LOC

no h/o seizures or fits

no h/o loss of power in any of the limbs

no h/o of any sensory disturbances like tingling/numbness/loss of sensation in any part of his body. pt. is able to appreciate pain, touch and temperature sensations

no h/o bowel and bladder disturbances

no h/o other cranial nerve dysfunction like visual disturbances/diplopia/dysphagia/nasal regurgitation

h/o exposure to o.p. compounds is present as patient is a farmer.

past history

there is no h/o similiar complaints in the past. patient has no h/o of any major illness like HT/DM/TB. there is no h/o previous hospitalisation and this is his first time in a hospital.

family history

patient is married since 40 years with a healthy wife and 3 sons who seem to be in good health. there is no h/o similiar complaints in any other member of the family. no h/o HT/TB/DM or any other major illness in the family.

personal history

diet - vegetarian

appetite - decreased due to lack of general well being

sleep - good,undisturbed

micturition - 3-4 times/day

bowels - 1 time/day

habits - patient used to be a smoker 15 years back, about 3-4 beedis/day. patient is a teetotaller and denies even tasting alcohol. patient denies any pre-marital or extra-marital sexual contact.

socio-economic history

patient is a farmer and hails from a poor socio-economic background

general physical examination

patient is an elderly male, poorly built and nourished, conscious and co-operative and well oriented to time place and person

vital signs:

pulse - 82 bpm, regular, moderate volume/force/tension, normal character, condition of the vessel wall is normal, no radio-radial/radiofemoral delay, all peripheral pulses are well felt

blood pressure - 130/80mm of hg in the right upper limb in the supine position

respiratory rate - 20 cycles/min, regular, abdomino-thoracic type

temp - pt. is afebrile

height -

weight -

scalp - nil

eyes - palpebral conjunctiva - pallor

sclera - nil

cornea - arcus senilis

pupils - normal and reactive

lens - cataract in the left eye

nose - nil

oral cavity - tongue - pale

mucosa - pale

ears - nil

facies - nil

neck - nil

upper limbs - pale nails

chest - pectus excavatum

abdomen - nil

lower limbs - nails - pallor, koilonoichia

no icterus/cyanosis/clubbing/lymphadenopathy/oedema

no neurocutaneous markers

systemic examination

central nervous system

higher mental functions:

consciousness - normal

memory - normal

intelligence - normal

no hallucinations or delusions

well oriented to time place and person

speech - is normal, however dysarthria is present

cranial nerves:

1st nerve - normal

2nd nerve - visual acuity(finger counting) - normal

field of vision - normal

colour vision - normal

fundoscopy - papilledema

3rd, 4th and 6th nerves - no diplopia/squint/ptosis

conjugate ocular movts. are normal

individual eyeball movts are normal b/l

direct and indirect reflexes normal b/l

nystagmus in the left eye on looking to the left

5th nerve - corneal and conjunctival reflexes absent, otherwise norm

7th nerve - left 7th nerve palsy of lmn type

8th nerve - right ear - rinne positive(ac>bc)

left ear - rinne negative(bc>ac)(false negative)

weber's lateralized to the right ear(left sided pure neural hearing loss)

9th and 10th nerves - normal

11th nerve - normal

12th nerve - normal

motor system:

nutrition - normal

tone - right left

wrist............................................. normal hypotonia

elbow............................................ normal hypotonia

knee............................................. normal hypotonia

ankle............................................ normal hypotonia

power - grade 5 in all limbs

co-ordination

a)finger-nose test.................................... normal incoordination

b)finger-nose-finger test.......................... normal incoordination

c)heel-knee test...................................... normal incoordination

d)tandem walking.................................... sways to the left..........................

conclusion - left upper and lower limb incoordination present

abnormal movements - no abnormal movements like tremors/fasciculations/athetosis/chorea

reflexes - superficial - all superficial reflexes are absent b/l

plantar - b/l flexor

- deep tendon reflexes - all dtr's are normal, however the knee jerk is pendular b/l

no ankle/patellar clonus

sensory system:

all sensations are intact - touch,pain,temp,posterior column

cortical sensations are intact

cerebellar signs:

left sided nystagmus in the left eye

dysarthria

left sided hypotonia

left sided past pointing

pendular knee jerk

broad based gait

left sided dysdiadochokinesia

left sided dysmetria

no rebound phenomenon

no intentional tremor

miscellaneous:

skull and spine - normal

no s/o meningitis

no neurocutaneous markers

no carotid bruits

cardiovascular system - NAD

respiratory system - NAD

abdominal system - NAD

structures involved:

left 7th nerve

left 8th nerve

left cerebellar hemisphere

differential diagnosis:

left cerebellopontine angle mass - neoplasm - acoustic neuroma/medulloblastoma/meningioma/astrocytoma/hemangioblastoma/ pontine glioma/cholesteatoma/metastatic deposits

intracerebral hematoma

intracerebral abscess

arachnoidal cyst

a-v malformations(basilar artery ectasia)

left cerebellopontine angle irritation caused by local meningeal involvement - TB/neurosyphilis