A young adult male presented with monoparesis. A case study. Upper limb progressive monoparesis.

1. “A Young Adult Male
with
Right sided Monoparesis”
Dr. Md. Mamunul ABEDIN
Assistant Registrar
Dept. Of Physical Medicine & Rehabilitation
Shaheed Suhrawardy Medical College Hospital

2. Particulars of the patient
▪ Name : Mr. Saddam Hossain
▪ Age : 27 years
▪ Sex : Male
▪ Marital status : Unmarried
▪ Occupation : Service holder
▪ Religion : Islam
▪ Present Address : Chattogram
▪ Date of Admission : 22.11.2021
▪ Date of Examination : 22.11.2021

3. Presenting Complaints
1. Right upper limb weakness for 10 months

4. H/O Present Illness
Patient states that he was relatively well 10
months back. Then he develops weakness of his
right hand which is gradual in onset and
progressing day by day. He also noticed wasting
of his right upper arm especially at hand and
forearm. This weakness is not associated with
any pain or numbness. He gave h/o fall on

5. ground with outstretched hand after a high
jump 10 months back. On further questioning,
he mentioned clumsiness of his right hand on
holding a computer mouse for short period of
time, and fasciculation which is also
progressing slowly over the last 3 years. He has
no neck pain, fever, night sweats, weight loss.
H/O Present Illness (contd.)

6. For these difficulties, he is having problem with
grooming, dressing, holding an object but pen,
lifting & carrying heavy objects.
H/O Present Illness (contd.)

7. H/O Past Illness
• Nothing significant

8. Socio-Economic Condition
• Patient belongs to middle socio-economic status
• Monthly income is average 15,000 BDT
• Lives in semi-pakka house & uses sanitary
latrine
• Drinks boiled water & takes usual Bangladeshi
diet

9. Personal History
• Non - smoker, non alcoholic
• No habit of chewing betel leaf

10. Psychosocial history
• He is a practicing Muslim, merely satisfied
with his way of living and quality of life
• Not involved in any kind of litigation

11. Family History
• Unmarried
• Has 2 brothers and 1 sister
• All of his family members are apparently in good
health
• No h/o similar type of illness or tuberculosis
among the first degree relatives

12. Immunization History
Patient is immunized as per EPI schedule
including BCG vaccination.

13. Drug History
• He had taken painkillers for short period of
time prescribed by local doctors for his trauma
• Currently taking no medications

14. Clinical Examination

15. General Examination
▪ Appearance : Anxious
▪ Body build : Average
▪ Co-operation : Co-operative
▪ Decubitus : On choice
▪ Anaemia : Absent
▪ Jaundice : Absent
▪ Cyanosis : Absent
▪ Oedema : Absent
▪ Dehydration : Absent

16. ▪ Clubbing : Absent
▪ Koilonychia : Absent
▪ Leuconychia : Absent
▪ Lymph nodes : Not Palpable
▪ Neck vein : Not engorged
▪ Thyroid gland : Not enlarged
▪ Nail changes : Absent
▪ Skin : Normal
General Exam (contd.)

17. • Pulse rate : 78 bpm
• Blood pressure : 120/80 mm Hg
• Temperature : 98.6° F
• Respiratory rate: 14/min
• Height : 1.65 m
• Weight : 53 Kg
• BMI : 19 Kg/m²
General Exam (contd.)

18. Systemic Examination

19. Nervous system Examination :
Higher psychic function : Normal
Gait : Normal
Speech : Normal
Signs of Meningeal Irritation : Absent
Cranial nerves : Intact

20. Examination of Motor System :
Bulk of Muscles :
Right Left
Shoulder All groups Normal Normal
Elbow
Extensor Group Wasted Normal
Flexor Group Wasted Normal
Hand
Thenar Wasted Normal
Hypothenar Wasted Normal
Dorsal Guttering Present Normal
Lower
Limbs
All groups Normal Normal

21. Examination of Motor System (contd.):

22. Examination of Motor System (contd.):

23. Examination of Motor System (contd.):

24. Examination of Motor System :
Right Left
Upper Limb Normal Normal
Lower Limb Normal Normal
Muscle Tone:
Ankle Clonus: Absent

25. Power of muscles :
Upper Limbs :
Right Left
Shoulder Abductors 5/5 5/5
Elbow
Flexors 5/5 5/5
Extensors 5/5 5/5
Wrist
Flexors 5/5 5/5
Extensors (ECRL) 4/5 5/5
Finger
Extensors
ED 4/5 5/5
Examination of Motor System (contd.):

26. Power of muscles :
Upper Limbs :
Right Left
Finger Flexors
FPL (Thumb) 5/5 5/5
FDP (2nd & 3rd) 5/5 5/5
FDP (4th & 5th) 5/5 5/5
Finger Abduction 1st DI 3/5 5/5
Finger Adduction 3/5 5/5
Examination of Motor System (contd.):

27. Power of muscles :
Upper Limbs :
Right Left
Thumb Abduction 0/5 5/5
Thumb Extension 0/5 5/5
Thumb Opposition 5/5 5/5
Examination of Motor System (contd.):

28. Power of muscles :
Lower Limbs :
Right Left
Hip
Flexor 5/5 5/5
Extensor 5/5 5/5
Knee
Flexors 5/5 5/5
Extensors 5/5 5/5
Ankle
Dorsiflexors 5/5 5/5
Plantar flexors 5/5 5/5
Evertors 5/5 5/5
Invertors 5/5 5/5
Great Toe Extension 5/5 5/5
Examination of Motor System (contd.):

29. Deep Tendon Reflexes :
Biceps Triceps Supinator Knee Ankle
Right Normal Normal Normal Normal Normal
Left Normal Normal Normal Normal Normal
Examination of Motor System (contd.):

30. Deep Tendon Reflexes :
Biceps Triceps Supinator Knee Ankle
Right Normal Normal Normal Normal Normal
Left Normal Normal Normal Normal Normal
Examination of Motor System (contd.):

31. Plantar Reflex : Flexor bilaterally
Hoffmann’s reflex : Negative bilaterally
Coordination : Normal
Examination of Motor System (contd.):

32. • Paper sign : Possible
• Rock/ Stone sign : Possible
• OK sign : Possible
• Ceiling test : Positive
• Scissor sign : Weak
• Froment sign : Negative
• Card Test : Positive
Rapid Assessment of Motor Function
(Hand)

33. • Pain : Normal
• Touch : Normal
• Temperature : Normal
• Vibration : Normal
• Joint Position Sense : Normal
• Two Point Discrimination : Normal
• Point Localization : Normal
Examination of Sensory System:

34. Locomotor System
Gait : Normal
Upper limbs (Arms)
All the joints of upper limbs are normal.
• On right side, Wasting of forearm & hand; thumb
is adducted and flexed; ulnar clawing present.
• No visible swelling
• No tenderness present over joint line
• Range of motion: Normal

35. Lower Limbs (Legs)
All the joints of Lower limbs are normal.
• No visible swelling, deformity or wasting
• No tenderness present over joint line
• Range of motion: Normal
Locomotor System (contd.)

36. Spine
Look: Cervical lordosis : Normal
Lumber lordosis : Normal
No visible swelling, gibbus or deformity
Feel: Tenderness : Absent
Local temperature : Normal
Step sign : Negative
Move: Normal
Locomotor System (contd.)

37. • Respiratory System
• Alimentary System
• Cardiovascular system
• Genitourinary system
Examination of these systems revealed no
apparent abnormality
Examination of Other Systems:

38. Functional Examination:
Ambulation No difficulties
Transfer No difficulties
Dressing Skill Can put on and take off clothes
but difficulty in buttoning,
unbuttoning, lacing shoes
Eating Skill No difficulties
Personal Hygiene No difficulties
Communication No difficulties

39. Mr. Saddam Hossain, 27 years, unmarried
male, muslim, service holder, normotensive,
non-diabetic, non-asthmatic hailing from
Chattogram presented with weakness and
wasting of right upper limb for last 10 months
which is gradual in onset, slowly progressing
over time, not associated with any pain or
numbness.
Salient Features

40. He has history of fall on ground with outstretched
right hand prior to onset of this problem. He also
complained clumsiness of same hand for last 3
years which occurred after using computer mouse
for short period of time. He has no neck pain,
fever, night sweats, weight loss or any problem in
other limbs.
Salient Features (contd.)

41. On examination, Patient is anxious with stable
vital signs. His right forearm, thenar &
hypothenar muscles are wasted with dorsal
guttering and ulnar clawing. Right thumb is
adducted and flexed. Wrist & finger extension is
4/5, Finger abduction & adduction is 3/5,
Thumb abduction & Extension is 0/5 on right
Salient Features (contd.)

42. side with normal muscle tone. Ceiling test, Card test
& Scissor test is positive. Deep tendon reflexes are
normal with negative Hoffman’s reflex. There is no
sensory abnormality. Examination of other limbs,
spine and other systemic examinations reveals no
abnormality. Due to his conditions, buttoning-
unbuttoning of shirt, lacing shoes, lifting & carrying
weights are difficult for him.
Salient Features (contd.)

43. ?
PROVISIONAL DIAGNOSIS

44. Provisional diagnosis
Monomelic Amyotrophy

45. Differential diagnosis
• Brachial Plexopathy
• Intracranial Space Occupying Lesion
• Cervical Cord Compression

46. Investigations:
• CBC, ESR
• RBS
• CPK
• CXR PA view
• X-ray Cervical Spine both view
• NCS & EMG of Right Upper Limb
• MRI of Brachial Plexus

47. Confirmatory Diagnosis

48. Management
Objectives:
• To improve muscle strength
• To improve hand functions
• To prevent hand deformity
• To improve quality of life

49. • Non-Pharmacological
• Pharmacological
Management (contd.)

50. Non-Pharmacological
• Patient education
• Physical Therapy & Exercises
• Occupational Therapy

51. Patient Education
• Nature of the disease
• Prognosis
• Treatment options
• Importance of exercises

52. Exercises
• Stretching & Strengthening Exercises
• Intrinsic hand muscle exercises

53. Occupational Therapy

54. Pharmacological Management
• Tab. Vitamin B1, B6, B12
• Cap. Pregabalin

55. Future Plan
• To treat underlying cause
• Orthotics