lower limb case discussion

Question 1

What type of joint is a knee joint?

Answer 1

Compound joint

Question 2

What are tibial collateral ligament and fibular collateral ligament

Answer 2

Modifications of thigh muscles

Question 3

Key stabiliser of knee joint

Answer 3

Extenstor ( Quadriceps Femoris) and Flexors

Question 4

Semitendenous innervation

Answer 4

Tibial division of the sciatic nerve

Question 5

Semimembranous innervation

Answer 5

Tibial division of the sciatic nerve

Question 6

Biceps femoris innervation

Answer 6

Long head: Tibial division of sciatic nerve
Short head: Common peroneal division of sciatic nerve

Question 7

Gracilis innervation

Answer 7

Obturator nerve

Question 8

Gastrocnemius innervation

Answer 8

Tibial nerve

Question 9

Popliteus innervation

Answer 9

Tibial nerve

Question 10

Function of ACL

Answer 10

prevents

1) Knee hyperextension
2) Posterior femoral displacement
3) Anterior tibial displacement
in the flexed knee

Question 11

Function of PCL

Answer 11

PCL

1) Tightens during knee flexion and prevents hyperflexion and posterior tibial displacement
2) Supports body weight when knee is flexed
3) Stronger cruciate ligament

Question 12

CASE 1: A 21 year old athlete feels sudden sharp pain in the back of his thigh while sprinting. Site of injury?

Answer 12

Hamstrings

Question 13

CASE 1: A 21 year old athlete feels sudden sharp pain in the back of his thigh while sprinting. Site of injury: Hamstrings
Innervated by: Tibial part of sciatic nerve
Which attaches to pes anserinus?

Answer 13

Semitendinous

Question 14

CASE 1: A 21 year old athlete feels sudden sharp pain in the back of his thigh while sprinting. Site of injury: Hamstrings
Innervated by?

Answer 14

Tibial part of sciatic nerve

Question 15

Superior gluteal nerve innervates?

Answer 15

Gluteus minimus, medius and tensor fascia latae

Question 16

How to assess strength of gluteus medius muscles?

Answer 16

When standing on one leg, if the pelvis tilts or drops on the side of the non-weight-bearing leg (known as a Trendelenburg sign), it suggests weakness in the gluteus medius of the standing leg.

Question 17

Gluteus maximus vs Hamstring

Answer 17

Hamstring: Extension of hip on flat surface (ie walking)
Gluteus Maximus: Extension of hip with fully flexed knee (ie climbing)

Question 18

CASE 2
* A 70 year old woman fell in her bathroom.After her fall, she could
not get up or even move her right leg.
* At orthopaedic clinic, examination findings include
1. patient’s right foot was pointing laterally
2. right lower limb was found shorter compared to the left lower limb
3. X ray revealed subcapital fracture of neck of right femur

What is the most common cause of this type of fracture in elderly woman following a trivial fall?

Answer 18

Osteoporosis

Question 19

How to measure length of lower limb?

Answer 19

Anterior superior illiac spine to medial mallelous

Question 20

CASE 2:
* A 70 year old woman fell in her bathroom.After her fall, she could
not get up or even move her right leg.
* At orthopaedic clinic, examination findings include
1. patient’s right foot was pointing laterally
2. right lower limb was found shorter compared to the left lower
limb
3. X ray revealed subcapital fracture of neck of right femur

Why is there a shortening of lower limb in this case?

Answer 20

Compression fracture (common cause is osteoperosis)

Question 21

Lateral rotators of hip joint

Answer 21

Short muscles
- Piriformis
- Superior gemellus
- Obturator internus
- Inferior gemellus
- Quadratus femoris
- Obturator externus

Question 22

CASE 3: A 21 year old man suffers an injury to his right knee during skiing. He complains of pain in his right knee and finds difficult to stand after sitting for a while. MRI reveals torn ACL. Both menisci and other ligaments were intact. Which of the following ligaments is attached to medial meniscus?

Answer 22

Tibial collateral ligament

Question 23

CASE 3: A 21 year old man suffers an injury to his right knee during skiing. He complains of pain in his right knee and finds difficult to stand after sitting for a while. MRI reveals torn ACL. Both menisci and other ligaments were intact. When the knee is flexed at 90 degree, the ligament that prevents the anterior movement of tibia is?

Answer 23

ACL

Question 24

Medial meniscus tear might be accompanied by

Answer 24

TCL and maybe ACL idk help me

Question 25

Non traumatic reasons for knee pain

Answer 25

1) OA 2) RA 3) Gout 4) Pseudogout 5) Bursitis 6) Gonococcal 7) Septic Arthritis 8) Psoriatic Arthritis

Question 26

Three signs of RA

Answer 26

1) cardinal signs of inflammation (pain, warmth, loss of function, redness) 2) Morning Stiffness 3) Pain while rest

Question 27

External + lateral rotation of leg

Answer 27

Fracture

Question 28

Internal + medial rotation of leg

Answer 28

Dislocation of hip posteriorly

Question 29

Why do we have to quickly relocate hip joint?

Answer 29

Prevent ischaemia (before 6 hours) since blood vessels can be badly disrupted

Question 30

CASE 4: ▪ 85 year old man ▪ Slipped in the toilet ▪ Unable to get up from the floor Diagnosis:?

Answer 30

Neck of femoral fracture (most common hip pain cause is neck of femoral fracture)

Question 31

Risk of untreated neck of femoral fracture? (IMPORTANT!)

Answer 31

Fracture of the neck of the femur often disrupts the blood supply to the head of the femur. The medial circumflex femoral artery supplies most of the blood to the head and the neck of the femur. Its retinacular arteries often are torn when the femoral neck is fractured or the hip joint is dislocated. In some cases, the blood supplied to the femoral head through the artery to the ligament of the femoral head may be the only remaining source of blood to the proximal fragment. This artery is frequently inadequate for maintaining the femoral head; consequently, the fragment may undergo aseptic vascular necrosis.

Question 32

Who are likely to get neck of femoral fractures?

Answer 32

More common in individuals > 60 years, especially in women because their femoral necks are often weak and brittle as a result of osteoperosis

Question 33

CASE 4: ▪ 85 year old man ▪ Slipped in the toilet ▪ Unable to get up from the floor Diagnosis: Femoral Neck Fracture Treatment:?

Answer 33

1) Take away the head of the femur and replace it with an artificial head so that the socket is left intact. 2) Metal screws or pins are inserted to hold the fractured bone in place while it heals. Sometimes a dynamic hip screw (DHS) or cannulated screws are used.

Question 34

CASE 5: ▪ 50 year old man with gradually worsening right thigh pain ▪ Limping ▪ Occasional fevers Diagnosis:?

Answer 34

Osteomyelitis

Question 35

CASE 5: ▪ 50 year old man with gradually worsening right thigh pain ▪ Limping ▪ Occasional fevers Diagnosis: Osteomyelitis Xray: ?

Answer 35

1) Lytic appearance - Lesions appear as darker (radiolucent) areas because they have less bone tissue than the surrounding healthy bone. 2) Sclerosis 3) Periosteal reactions

Question 36

Osteosarcoma vs Bone metastasis imaging

Answer 36

Bone metastasis - disappearing bone Osteosarcoma - Haziness (refer to notes for pictures)

Question 37

CASE 5: ▪ 59 year old lady ▪ On and off pain in the knee for a year ▪ Knee stiffer than before ▪ Cannot walk as far as usual Diagnosis:?

Answer 37

Diagnosis: Osteoarthritis

Question 38

CASE 5: ▪ 59 year old lady ▪ On and off pain in the knee for a year ▪ Knee stiffer than before ▪ Cannot walk as far as usual Diagnosis: Osteoarthritis Pathophysiology: ?

Answer 38

In OA, the articular cartilage covering the ends of the bones (tibia and femur in the knee joint) gradually breaks down due to wear and tear, inflammation, and mechanical stress. As the cartilage thins and degenerates, the joint space narrows. This narrowing is a hallmark feature of OA seen on X-rays. (refer to notes for picture) Without sufficient cartilage, the bones come closer together, increasing bone-on-bone contact. With less cartilage to absorb shock, pressure on the joint surfaces increases. This leads to increased friction between the bones, causing further joint damage and contributing to pain and stiffness. The increased pressure and friction result in the development of bony growths (osteophytes) and inflammation of the synovium. This leads to joint stiffness, especially after periods of inactivity or in the morning. Mechanical pain occurs during movement, as the joint surfaces experience more friction and pressure. Pain is typically worse with activity and relieved by rest.

Question 39

CASE 6: ▪ 44 year old lady ▪ 6 weeks of leg pain from the buttock to the calf ▪ Worse sitting for long periods Further questions to ask?

Answer 39

1) Numbness or tingling 2) Back pain

Question 40

CASE 6: ▪ 44 year old lady ▪ 6 weeks of leg pain from the buttock to the calf ▪ Worse sitting for long periods Diagnosis?

Answer 40

Sciatica

Question 41

CASE 6: ▪ 44 year old lady ▪ 6 weeks of leg pain from the buttock to the calf ▪ Worse sitting for long periods Diagnosis: Sciatica What causes sciatica?

Answer 41

The outer layer of the disc (annulus fibrosus) weakens or tears due to degeneration or trauma. This allows the softer inner core (nucleus pulposus) to herniate out through the fibrous tissue. The herniated disc material can either protrude into the spinal canal or sequester (fully extrude into the canal), pressing on the nearby nerve roots (typically the L4-L5 or L5-S1 nerve roots, affecting the sciatic nerve). The herniated disc exerts pressure on the sciatic nerve or its roots, leading to pain, stiffness, and nerve dysfunction along the nerve’s distribution (from the lower back to the leg and foot). Compression of the nerve can result in disrupted signals to muscles, leading to muscle weakness, stiffness, and sometimes loss of motor function in the affected leg. This can manifest as foot drop—the inability to lift the foot properly during walking.

Question 42

CASE 6: ▪ 44 year old lady ▪ 6 weeks of leg pain from the buttock to the calf ▪ Worse sitting for long periods Diagnosis: Sciatica Treatment: ?

Answer 42

1) Traction Exercise 2) Medication

Question 43

CASE 7: ▪ 20 year old girl ▪ Injury to right knee during volleyball ▪ Initial knee swelling ▪ Knee pain and limping for 3 weeks, not getting better Diagnosis?

Answer 43

Bucket Handle Tear/ Meniscus Tear

Question 44

CASE 7: ▪ 20 year old girl ▪ Injury to right knee during volleyball ▪ Initial knee swelling ▪ Knee pain and limping for 3 weeks, not getting better Diagnosis: Meniscus Tear When does it occur?

Answer 44

1) usually happens if you change your direction quickly 2) if you have a previous injury --> predisposes to a current injury

Question 45

What's housemaid's knee?

Answer 45

Inflammed prepatellar bursa

Question 46

CASE 8: ▪ 60 year old man ▪ Diabetic ▪ Knee swelling and pain for 2 days ▪ Unwilling to be examined ▪ Feverish and lethargic Diagnosis?

Answer 46

Septic joint arthritis Differential: Swelling after blood thinner

Question 47

CASE 9: ▪ 32 year old lady twisted her foot going down the stairs ▪ Could walk initially but after a few hours pain worsened and unable to walk Diagnosis:?

Answer 47

Likely fracture (can walk so unlikely ligament tear)

Question 48

Function of talocrural Joint

Answer 48

Up down - This is the primary ankle joint, formed between the tibia, fibula, and talus. It allows for dorsiflexion and plantar flexion.

Question 49

Function of subtalar joint

Answer 49

Left right - Located below the talus, this joint allows for inversion and eversion of the foot, contributing to the foot's ability to adapt to uneven surfaces.

Question 50

CASE 10: A 4-year-old boy is brought to the clinic by his parents due to frequent falls and difficulty getting up from the floor. They also note that he walks on his toes and has a waddling gait. On examination, you observe that he uses his hands to push off his thighs to stand up from a sitting position (Gower’s sign). His calf muscles appear enlarged. There is a family history of muscle disease in maternal male relatives. Diagnosis:?

Answer 50

Duchenne Muscle Dystrophy Duchenne muscular dystrophy (DMD) typically presents in early childhood with progressive muscle weakness, difficulty rising from the floor (Gower’s sign), a waddling gait, and calf muscle pseudohypertrophy.

Question 51

What is the inheritance pattern of Duchenne muscular dystrophy

Answer 51

X- linked recessive

Question 52

Compare Duchenne and Becker's muscle dystrophy

Answer 52

Simalarity: Both occur due to a mutation in the dystrophin gene Different: Duchenne is nonsense mutation while Becker's is missense mutation.

Question 53

CASE 10: A 4-year-old boy is brought to the clinic by his parents due to frequent falls and difficulty getting up from the floor. They also note that he walks on his toes and has a waddling gait. On examination, you observe that he uses his hands to push off his thighs to stand up from a sitting position (Gower’s sign). His calf muscles appear enlarged. There is a family history of muscle disease in maternal male relatives. Diagnosis: Duchenne's muscle dystrophy Explain the presentation.

Answer 53

Waddling gait - calf pseudohypertrophy --> enlarged from fat and fibrosis Gower's sign - weak muscles in the hip and upper legs later symptoms: - wheelchair - respiratory failure - scoliosis - dilated cardiomyopathy - arrythmia

Question 54

CASE 10: A 4-year-old boy is brought to the clinic by his parents due to frequent falls and difficulty getting up from the floor. They also note that he walks on his toes and has a waddling gait. On examination, you observe that he uses his hands to push off his thighs to stand up from a sitting position (Gower’s sign). His calf muscles appear enlarged. There is a family history of muscle disease in maternal male relatives. Diagnosis: Duchenne's muscle dystrophy Lab results?

Answer 54

1) High creatine kinase 2) Mutations in dystrophin - DNA test - Western blot 3) Muscle biopsy

Question 55

CASE 10: A 4-year-old boy is brought to the clinic by his parents due to frequent falls and difficulty getting up from the floor. They also note that he walks on his toes and has a waddling gait. On examination, you observe that he uses his hands to push off his thighs to stand up from a sitting position (Gower’s sign). His calf muscles appear enlarged. There is a family history of muscle disease in maternal male relatives. Diagnosis: Duchenne's muscle dystrophy Treatment:?

Answer 55

1) Glucocorticoids --> Side effects: Weight gain 2) Physical therapy and conditioning -->

Question 56

CASE 11: A 65-year-old man underwent a cardiac catheterization procedure via a right femoral artery puncture. Six hours later, he complains of pain and swelling in the right groin area. On examination, there is a pulsatile mass at the puncture site, with a bruit heard over the area. His right foot pulses are palpable but slightly diminished compared to the left side. Diagnosis: ?

Answer 56

Femoral artery pseudoaneurysm A pulsatile mass with a bruit following a femoral artery puncture is highly suggestive of a pseudoaneurysm. This complication can occur when blood leaks out of the arterial puncture site into the surrounding tissue but remains contained by the surrounding tissue, forming a sac

Question 57

CASE 12: A 45-year-old male presents with a complaint of numbness and a burning sensation on the outer part of his right thigh. He notes that these symptoms worsen when he stands for long periods or when wearing tight clothing. He denies any weakness or pain in his leg. Physical examination reveals decreased sensation over the lateral aspect of the thigh but no motor deficits.

Answer 57

Meralgia paresthetica is caused by compression or entrapment of the lateral cutaneous nerve of the thigh, often resulting in numbness, tingling, or burning pain over the lateral aspect of the thigh without motor involvement.

Question 58

CASE 13: A 55-year-old woman presents with pain and a visible bump on the inner side of her right big toe. She notes that the pain worsens when she wears tight or narrow shoes. On examination, there is a prominence over the first metatarsophalangeal (MTP) joint, and the big toe is deviated laterally towards the other toes. There is tenderness over the bunion but no significant redness or swelling.

Answer 58

(tight shoes so most likely) Hallux valgus Hallux valgus, commonly known as a bunion, presents with a bony prominence at the base of the big toe (first MTP joint) and lateral deviation of the toe. It is often exacerbated by tight footwear and is characterized by pain over the affected joint.

Question 59

CASE 14: A 32-year-old man presents with progressive muscle weakness and stiffness, particularly in his hands and face. He reports difficulty releasing his grip after shaking hands or holding objects. He also mentions excessive daytime sleepiness, cataracts, and a family history of a similar condition. On examination, he has bilateral facial muscle weakness, frontal balding, and delayed muscle relaxation after a handshake. Diagnosis:?

Answer 59

Myotonic dystrophy Myotonic dystrophy is characterized by progressive muscle weakness and myotonia (delayed muscle relaxation). The condition often involves facial muscle weakness, frontal balding, cataracts, and systemic features like sleep disturbances. A family history and difficulty releasing grip are key diagnostic clues

Question 60

CASE 14: A 32-year-old man presents with progressive muscle weakness and stiffness, particularly in his hands and face. He reports difficulty releasing his grip after shaking hands or holding objects. He also mentions excessive daytime sleepiness, cataracts, and a family history of a similar condition. On examination, he has bilateral facial muscle weakness, frontal balding, and delayed muscle relaxation after a handshake. Diagnosis: Myotonic Dystrophy Clinical presentations?

Answer 60

1) Weakness / wasting of facial muscles 2) Frontal baldness 3) Bilateral ptosis 4) Sternocleiomastoid weakness 5) Gynaecomastia 6) Distal limb wasting / weakness - foot drop 7) Grip myotonia 8) Percussion myotonia

Question 61

CASE 14: A 32-year-old man presents with progressive muscle weakness and stiffness, particularly in his hands and face. He reports difficulty releasing his grip after shaking hands or holding objects. He also mentions excessive daytime sleepiness, cataracts, and a family history of a similar condition. On examination, he has bilateral facial muscle weakness, frontal balding, and delayed muscle relaxation after a handshake. Diagnosis: Myotonic Dystrophy Complications?

Answer 61

Eyes - Cataract Cardiac - Arrythmia - Cardiomyopathy Pulmonary - OSA Endocrine - Hypogonadism - Diabetes mellitus - Thyroid GI - Dysphagia

Question 62

CASE 14: A 32-year-old man presents with progressive muscle weakness and stiffness, particularly in his hands and face. He reports difficulty releasing his grip after shaking hands or holding objects. He also mentions excessive daytime sleepiness, cataracts, and a family history of a similar condition. On examination, he has bilateral facial muscle weakness, frontal balding, and delayed muscle relaxation after a handshake. Diagnosis: Myotonic Dystrophy Investigations:?

Answer 62

- Opthamologist - ECG, 24 hr holter echocardiogram - Sleep study, pulmonary function test, hba1c and thyroid test

Question 63

CASE 15: A 50-year-old male, presented to the outpatient clinic with complaints of persistent severe pain and swelling in his right ankle of three days duration. The symptoms started acutely three days ago in the morning, limiting his ability to walk and perform daily activities. He had three other episodes of right big toe pain and swelling in the past 6 months, which lasted for only one to two days and recovered well after self medication with ibuprofen. * The man has a history of hypertension, for which he has been on amlodipine 5 mg daily for the past five years. He denies any history of diabetes, chronic kidney disease, or cardiovascular events. His family history is notable for gout, as his father and older brother also suffer from the condition. He is a non-smoker and consumes alcohol occasionally, typically 1-2 glasses of wine per week. * On physical examination, the man appeared in distress due to pain. His right ankle was visibly swollen, erythematous, and warm to the touch. There was limited range of motion due to pain. The left ankle and other joints were unremarkable. Vital signs were stable with a blood pressure of 135/85 mmHg, heart rate of 78 bpm, and no fever. What are the possible diagnoses for this man?

Answer 63

Diagnosis: Gout Differential: - Septic arthiritis (if inflammatory and monoarthirits always have this as differential) - OA - Ankle trauma

Question 64

CASE 15: A 50-year-old male, presented to the outpatient clinic with complaints of persistent severe pain and swelling in his right ankle of three days duration. The symptoms started acutely three days ago in the morning, limiting his ability to walk and perform daily activities. He had three other episodes of right big toe pain and swelling in the past 6 months, which lasted for only one to two days and recovered well after self medication with ibuprofen. * The man has a history of hypertension, for which he has been on amlodipine 5 mg daily for the past five years. He denies any history of diabetes, chronic kidney disease, or cardiovascular events. His family history is notable for gout, as his father and older brother also suffer from the condition. He is a non-smoker and consumes alcohol occasionally, typically 1-2 glasses of wine per week. * On physical examination, the man appeared in distress due to pain. His right ankle was visibly swollen, erythematous, and warm to the touch. There was limited range of motion due to pain. The left ankle and other joints were unremarkable. Vital signs were stable with a blood pressure of 135/85 mmHg, heart rate of 78 bpm, and no fever. What is the most important procedure to confirm the likely diagnosis?

Answer 64

1) Joint aspiration 2) Polarised microscopy --> to send synovial fluid to look for crystals and culture in grown strain

Question 65

CASE 15: A 50-year-old male, presented to the outpatient clinic with complaints of persistent severe pain and swelling in his right ankle of three days duration. The symptoms started acutely three days ago in the morning, limiting his ability to walk and perform daily activities. He had three other episodes of right big toe pain and swelling in the past 6 months, which lasted for only one to two days and recovered well after self medication with ibuprofen. * The man has a history of hypertension, for which he has been on amlodipine 5 mg daily for the past five years. He denies any history of diabetes, chronic kidney disease, or cardiovascular events. His family history is notable for gout, as his father and older brother also suffer from the condition. He is a non-smoker and consumes alcohol occasionally, typically 1-2 glasses of wine per week. * On physical examination, the man appeared in distress due to pain. His right ankle was visibly swollen, erythematous, and warm to the touch. There was limited range of motion due to pain. The left ankle and other joints were unremarkable. Vital signs were stable with a blood pressure of 135/85 mmHg, heart rate of 78 bpm, and no fever. What other prior symptom or current sign may help to confirm the diagnosis?

Answer 65

1) Previous episodes of acute monoarthritis 2) Tophi 3) Hyperuricemia

Question 66

CASE 15: A 50-year-old male, presented to the outpatient clinic with complaints of persistent severe pain and swelling in his right ankle of three days duration. The symptoms started acutely three days ago in the morning, limiting his ability to walk and perform daily activities. He had three other episodes of right big toe pain and swelling in the past 6 months, which lasted for only one to two days and recovered well after self medication with ibuprofen. * The man has a history of hypertension, for which he has been on amlodipine 5 mg daily for the past five years. He denies any history of diabetes, chronic kidney disease, or cardiovascular events. His family history is notable for gout, as his father and older brother also suffer from the condition. He is a non-smoker and consumes alcohol occasionally, typically 1-2 glasses of wine per week. * On physical examination, the man appeared in distress due to pain. His right ankle was visibly swollen, erythematous, and warm to the touch. There was limited range of motion due to pain. The left ankle and other joints were unremarkable. Vital signs were stable with a blood pressure of 135/85 mmHg, heart rate of 78 bpm, and no fever. What is the appropriate treatment plan?

Answer 66

1) NSAIDs 2) Colchines 3) Corticosteroids (cuz acute --> do not increase urate lowering agents during the attack can keep it at current dose) Long term: - lifestyle modifications

Question 67

CASE 15: A 50-year-old male, presented to the outpatient clinic with complaints of persistent severe pain and swelling in his right ankle of three days duration. The symptoms started acutely three days ago in the morning, limiting his ability to walk and perform daily activities. He had three other episodes of right big toe pain and swelling in the past 6 months, which lasted for only one to two days and recovered well after self medication with ibuprofen. * The man has a history of hypertension, for which he has been on amlodipine 5 mg daily for the past five years. He denies any history of diabetes, chronic kidney disease, or cardiovascular events. His family history is notable for gout, as his father and older brother also suffer from the condition. He is a non-smoker and consumes alcohol occasionally, typically 1-2 glasses of wine per week. * On physical examination, the man appeared in distress due to pain. His right ankle was visibly swollen, erythematous, and warm to the touch. There was limited range of motion due to pain. The left ankle and other joints were unremarkable. Vital signs were stable with a blood pressure of 135/85 mmHg, heart rate of 78 bpm, and no fever. What complications do you anticipate in this condition and how would you manage them?

Answer 67

1) Chronic gout 2) Kidney stone 3) Renal impairment

Question 68

CASE 16: A 45-year-old male presents with a complaint of numbness and a burning sensation on the outer part of his right thigh. He notes that these symptoms worsen when he stands for long periods or when wearing tight clothing. He denies any weakness or pain in his leg. Physical examination reveals decreased sensation over the lateral aspect of the thigh but no motor deficits. Which are unlikely?

Answer 68

Anything to do with sciatic and femoral nerve (they have motor abilities)

Question 69

CASE 16: A 45-year-old male presents with a complaint of numbness and a burning sensation on the outer part of his right thigh. He notes that these symptoms worsen when he stands for long periods or when wearing tight clothing. He denies any weakness or pain in his leg. Physical examination reveals decreased sensation over the lateral aspect of the thigh but no motor deficits. Diagnosis:?

Answer 69

Meralgia paresthetica Meralgia paresthetica is caused by compression or entrapment of the lateral cutaneous nerve of the thigh, often resulting in numbness, tingling, or burning pain over the lateral aspect of the thigh without motor involvement.

Question 70

CASE 16: A 45-year-old male presents with a complaint of numbness and a burning sensation on the outer part of his right thigh. He notes that these symptoms worsen when he stands for long periods or when wearing tight clothing. He denies any weakness or pain in his leg. Physical examination reveals decreased sensation over the lateral aspect of the thigh but no motor deficits. Treatment:?

Answer 70

Loose clothing/ lose weight

Question 71

CASE 17: A 60-year-old male presents with a complaint of pain in his right knee for the past three months. He reports that the pain worsens with activity and improves with rest. He denies any history of knee trauma or injury. On examination, there is no tenderness or swelling in the knee joint, and the knee range of motion is normal. However, upon further examination, the hip range of motion is limited, particularly in internal rotation, and there is discomfort during hip movement. Which dermatome affected?

Answer 71

L3 - obturator nerve (with L3 nerve compartment)

Question 72

CASE 17: A 60-year-old male presents with a complaint of pain in his right knee for the past three months. He reports that the pain worsens with activity and improves with rest. He denies any history of knee trauma or injury. On examination, there is no tenderness or swelling in the knee joint, and the knee range of motion is normal. However, upon further examination, the hip range of motion is limited, particularly in internal rotation, and there is discomfort during hip movement. Diagnosis?

Answer 72

Referred pain from hip osteoarthritis Referred pain from hip osteoarthritis can present as knee pain due to the common nerve pathways shared by the hip and knee joints. Limited hip range of motion and discomfort during hip movement are key clues to suspect hip involvement.

Question 73

CASE 18: A 45-year-old male presents with lower back pain that radiates down the outer side of his left thigh, the front of his shin, and into the top of his foot. He also describes tingling and numbness in the same distribution. On examination, he has difficulty with dorsiflexion of the left foot and weakness in extending his big toe. The straight leg raise test is positive on the affected side. Diagnosis?

Answer 73

Prolapsed intervertebral disc with L5 radiculopathy L5 radiculopathy typically presents with pain radiating down the outer thigh, front of the shin, and into the top of the foot. Weakness in dorsiflexion of the foot and extension of the big toe are key signs of L5 nerve root involvement. tldr: L5 radiculopathy --> dorisiflexion + weakness of big toe

Question 74

CASE 19: A 48-year-old male presents with lower back pain that radiates down the back of his right leg to the sole and outer edge of his foot. He also reports numbness and tingling in the same area. On examination, there is weakness in plantar flexion of the right foot, and his Achilles tendon reflex is diminished on the affected side. The straight leg raise test is positive. Diagnosis?

Answer 74

Prolapsed intervertebral disc with S1 radiculopathy S1 radiculopathy often presents with pain radiating down the back of the leg to the sole and outer edge of the foot. Weakness in plantar flexion and a diminished Achilles tendon reflex are characteristic findings in S1 nerve root involvement. tldr: S1 radiculopathy -> achilles tendon affected - cannot plantar flex

Question 74

CASE 20: A 35-year-old male presents with difficulty lifting his right foot while walking and a tendency to trip over his toes. He has recently undergone a back surgery which required him to lie on his right side for a few hours during anaesthesia. There is weakness in dorsiflexion and eversion of the right foot, with sensory loss over the dorsum of the foot and lateral shin. The patient’s deep tendon reflexes are normal. Diagnosis?

Answer 74

Common peroneal nerve palsy Common peroneal nerve palsy often presents with foot drop (difficulty in dorsiflexion), weakness in eversion of the foot, and sensory deficits over the dorsum of the foot and lateral shin. It is frequently associated with activities that involve prolonged squatting or pressure on the lateral aspect of the knee.

Question 75

CASE 20: A 35-year-old male presents with difficulty lifting his right foot while walking and a tendency to trip over his toes. He has recently undergone a back surgery which required him to lie on his right side for a few hours during anaesthesia. There is weakness in dorsiflexion and eversion of the right foot, with sensory loss over the dorsum of the foot and lateral shin. The patient’s deep tendon reflexes are normal. Diagnosis: Common peroneal nerve palsy How to differentiate between common peroneal nerve palsy and L5 radiculopathy?

Answer 75

1) Location: common peroneal palsy is due to the pressure at the neck of fibula Common peroneal palsy can abduct/externally rotate hip while L5 radiculopathy cannot.

Question 76

Reflexes and their root value?

Answer 76

Ankle jerk - S1 Knee jerk - L3 + L4

Question 77

CASE 21: A 10-year-old boy presents with fever, headache, and muscle pain, which started three days ago. He now has new-onset weakness in his right leg, which is flaccid and shows no deep tendon reflexes. There are no sensory deficits noted. His vaccination history is unclear, and his parents mention that he did not receive routine immunizations as an infant.

Answer 77

Poliomyelitis Poliomyelitis typically presents with asymmetric flaccid paralysis without sensory loss. The presence of fever, muscle pain, and the absence of deep tendon reflexes in a child with an unclear vaccination history strongly suggests poliomyelitis. * attacks spinal cord * 3 types of serotype

Question 78

CASE 22: A 30-year-old woman presents with a history of progressive weakness that worsens with activity and improves with rest. She notices that her eyelids droop by the end of the day, and she has difficulty speaking clearly after talking for a long time. On examination, she has bilateral ptosis and mild weakness in her proximal muscles. There are no sensory deficits or changes in reflexes. Diagnosis: Myastenia Gravis What is the most appropriate initial test to confirm the suspected diagnosis?

Answer 78

Acetylcholine receptor antibody test The acetylcholine receptor antibody test is the most appropriate initial diagnostic test for myasthenia gravis, as it directly measures the presence of antibodies responsible for the disease. Although the Edrophonium test and EMG can also be used for diagnosis, the antibody test is more specific and is considered the gold standard for confirming myasthenia gravis.

Question 79

CASE 9: A 65-year-old woman presents with numbness and tingling in her hands and feet, accompanied by a sensation of pins and needles, and also oral ulcers. She has a history of total gastrectomy due to cancer of stomach two years ago. On examination, there is reduced sensation to light touch and vibration in a glove-and-stocking pattern. Muscle strength is preserved, but her deep tendon reflexes are decreased in the lower extremities. What should she test for?

Answer 79

Vitamin B12 level measurement Gastrectomy results in loss of parietal cells that produce intrinsic factor, resulting in vitamin B12 deficiency, which is a common cause of peripheral neuropathy. Measuring vitamin B12 levels is an important step in identifying the cause of neuropathy and initiating appropriate treatment

Question 79

CASE 22: A 30-year-old woman presents with a history of progressive weakness that worsens with activity and improves with rest. She notices that her eyelids droop by the end of the day, and she has difficulty speaking clearly after talking for a long time. On examination, she has bilateral ptosis and mild weakness in her proximal muscles. There are no sensory deficits or changes in reflexes. Diagnosis?

Answer 79

Myasthenia gravis Myasthenia gravis is characterized by SKELETAL muscle weakness that worsens with activity and improves with rest. Key features include ptosis, diplopia, and bulbar symptoms such as difficulty speaking. The absence of sensory deficits and normal reflexes helps differentiate it from other neuromuscular disorders. if sensory - consider guillan-baire syndrome if reflex increased - consider ALS

Question 80

CASE 23: A 55-year-old man with a long history of poorly controlled type 2 diabetes presents with numbness, tingling, and burning sensations in both feet that have been gradually worsening over the past year. He reports that the symptoms are worse at night and sometimes interfere with his sleep. On examination, there is decreased sensation to pinprick, vibration, and light touch in a “stocking” distribution over his feet. His reflexes at the ankles are diminished bilaterally.

Answer 80

Peripheral neuropathy Peripheral neuropathy is commonly seen in patients with diabetes and typically presents with symmetric sensory loss in a “stocking” distribution, starting in the feet and progressing proximally. The presence of decreased sensation and diminished reflexes, particularly in the lower limbs, is characteristic of diabetic neuropathy

Question 80

How does paresis present in upper and lower limb?

Answer 80

Paresis in the upper limb leads to flexion due to spasticity, while the lower limb is held in an extended position due to weakness or lack of control.

Question 81

CASE 24: A 45-year-old woman presents with pain on the outer side of her right hip, which started gradually over the past few weeks. The pain is worse when lying on her right side at night and when getting up from a chair after sitting for a long time. On examination, there is tenderness over the greater trochanter but no significant limitation in hip joint movement.

Answer 81

Trochanteric bursitis typically presents with lateral hip pain, tenderness over the greater trochanter, and pain that worsens with activities like lying on the affected side or rising from a seated position. Unlike hip osteoarthritis, trochanteric bursitis does not cause significant restriction in hip joint movement.