SPASTIC PARAPARESIS_HYPERTHYROIDISM A MIMICKER OF MOTOR NEURON DISEASE?

A 50 year old female patient, agricultural labourer by occupation presented to the General Medicine OPD with the complaints of weakness of lower limbs, insidious in onset, gradually progressive type since 2 years.

She was apparently asymptomatic 2 years back then she developed proximal muscle weakness in the lower limbs,initially in the right lower limb followed by left lower limb.
She had difficulty in getting up from sitting posture.

Sh doesnt give any history of loss of consciousness, seizures, giddiness, bowel/bladder incontinence,cranial nerve anbormalities,paresthesias in the limbs.

H/o Weight loss present.

Past history:Not a k/c/o Hypertension,Diabetes mellitus,Thyroid disorders,pulmonary kochs,epilepsy,asthma.

Family history:No history of similar complaints in the family.
Not a k/c/o Hypertension,Diabetes mellitus,Thyroid disorders,pulmonary kochs,epilepsy,asthma.

Personal history:
Mixed diet
Appetite adequate.
Bowel and bladder regular
No sleep disturbances present.
Non alcoholic
Non smoker

General physical examination-
Patient is lying supine on the examination couch.
Temp-98.6F
Heart rate- 100 bpm,regular on right radial artery
Blood pressure: 120/80mmhg in supine posture on right arm
No pallor,icterus,cyanosis,lymphadenopathy,clubbing,koilonychia,pedal edema.
All the peripheral pulses felt.

Staring look noticed.
Fine tremors noticed.
Fluttering over thyroid in the neck region noticed.

General systemic examination:

Central nervous system examination:

Patient is a right handed person, walking like having a magnetic gait,  especially using toe tips in left limb.

Higher intellectual function are intact.

All the cranial nerves are intact.

Motor system:

NUTRITION:
Wasting of thenar and hypothenar muscles in both the upper limbs and lower limb foot muscles.

TONE:
Hypertonia in both the upper and lower limbs.
Contractures present in lower limbs.

POWER:
4/5 in the upper limbs.
3/5 in the lower limbs.

REFLEXES:
Superficial reflexes: Corneal and conjunctival reflexes present.
                                 Abdominal reflex absent.
                                 Anal reflex present.
Deep tendon reflexes: Biceps,triceps,supinator,ankle exaggerated(++++)
                                    Knee absent
Plantae reflex: Not elicitable
Hoffmann's and Wartenburg's sign:Present.

Patellar clonus:Absent

Ankle clonus:Present.

Fasciculation seen over tongue.

Sensory system:Intact

Cerebellar system:
Finger-nose test:Able to do
Finger-finger test:Able to do
Dysdiadokinesia:Able to do
Romberg's test: Negative

Other systems examination:
Cardiovascular:S1S2 heard,No murmurs.
Respiratory system:Bilateral air entry present,Normal vesicular breath sounds heard.
Per abdomen: Soft,Non tender.
                       No organomegaly,Bowel sounds heard.

SPASTIC PARAPARESIS UNDER EVALUATION- ?THYROID MYOPATHY ?MOTOR NEURON DISEASE ?DIABETIC AMYOTROPHY

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