NEURO-MUSCULAR DDx Flashcards
My face doesn’t work right:
30 y/o short order cook comes
into the emergency room after
waking up earlier in the day with
numbness, tingling, and weakness
on the left side of his face. He is
having a little trouble with his
balance and can’t close his left eye.
What is the differential? 5
- Bell’s Palsy
- brain tumor
- stroke
- myasthenia gravis
- Lyme disease
- Which nerve is involved in Bell’s palsy?
- Upper and lower nerve regions affected how? 2
- Symptoms? 3
- Treatment? 2
- CN CVII
- -Lower nerve region (will be ipsilateral)
- Upper will cause paralysis of contralateral side and will just affect the lower portion of the face and not the forehead - See picture
- Steriods and eye patch
I can’t do my hair
60 year old ranch wife comes in complaining that for the last 2 months she has been unable to lift up her right arm. She has not been able to do her hair. She gets pain in her shoulder that makes it hard for her to sleep
- Differential diagnosis? 5
- Rotatory cuff tear
- Glenohumeral arthritis
- Axillary nerve palsy
- HNP C 5-6
‘5. Frozen shoulder’
- RTC: pain with resisted abduction, trick motions to get hand over head
- Arthritis: pain and limited motion, especially rotation
- Axillary nerve palsy – usually seen after anterior shoulder dislocation
- Herniated disc with pressure on C5, C6 nerve root
- Frozen shoulder: Adhesive capsulitis seen after injury or inflammatory process
My legs are getting weak
35 y/o plumber comes in complaining that for the last 2 or 3 days he is having trouble going up stairs. He notes some tingling in his hands. Today he feels a little short of breath. Two weeks ago he had the flu. Otherwise his medical history is unremarkable.
- Differential diagnosis? 5
- How should we make the diagnosis? 2 (how does it progress?)
- Treatment? 3
1.
- Guillan-Barre several sub-types
- auto-immune disease
- inflammatory polyneuropathies
- spinal cord disorders, cauda equina
- N-M junction disorders
2. CSF and EMG (acsending paralysis)
3.
- IV immunoglobulins – plasmapheresis
- respiratory support
- nutritional support
I CAN’T WALK LIKE I USED TO
A 75 year old male, retired accountant comes in because for the last 5 months he has not been able to exercise like he used to. For years he would walk several miles at a time and now has to stop after a block or two. After resting for 10 minutes he can go another block or two. He does not get calf pain. He has no upper extremity or torso weakness. His health is otherwise good. He has started using a cane.
- Differential Diagnosis? 4
- spinal stenosis
- cauda equina syndrome
- vascular claudication
- peripheral neuropathy
Describe the main symptoms of each diagnosis?
- spinal stenosis 2
- cauda equina syndrome 1
- vascular claudication 4
- peripheral neuropathy 1
- Spinal stenosis:
- do better bent over (grocery cart),
- may have to sit on stool to cook - Cauda equina:
- involvement of lumbar plexus: tumor, trauma, spinal stenosis, inflammatory diseases, bleed post surgery - Vascular claudication:
- peripheral arterial disease,
- strongly associated with smoking,
- diabetes, and
- hypertension – get calf pain - Neuropathy:
- more constant in symptoms, usually not improved with rest
My back is killing me
A 50 year old nurse is brought to the ED by her husband. As she was getting ready for work she developed low back pain that has progressed to the point where she has trouble walking and cannot get comfortable. She has had occasional mild back discomfort in the past. She has no recent falls or other trauma.
Differential diagnosis? 6
- disc rupture
- pathologic fracture
- cauda equina syndrome
- kidney stone/infection
- ruptured abdominal aorta
- pelvic tumor/infection
HOw would each of the following present?
- disc rupture
- pathologic fracture
- cauda equina syndrome
- kidney stone/infection
- ruptured abdominal aorta
- pelvic tumor/infection
1 HNP -would expect shooting pain down leg with weakness and nerve root signs
2 -Pathologic Fx associated with tumor in bone
- Cauda equina syndrome from inflammatory process
- Kidney stone – severe cramping pain, hematuria \
- Ruptured abdominal aorta. Can present as severe back pain, life threatening
- Pelvic inflammatory disease or tumor
MY ARM’S NOT RIGHT
50 year old farmer/rancher comes in because he is having trouble doing his chores. For the last several months (not sure of how long) he has found that he can’t grab and twist things with his right arm like before. He is having to do things with his left arm which is quite frustrating. No problems with his shoulder
Differential Diagnosis? 5
- torn distal biceps tendon (hook test)
- medial and lateral epicondylitis
- torn rotator cuff
- lesions cervical roots C4,5,6
- peripheral nerves
A 38 year old obese woman comes in for follow-up on her weight loss program. She has lost very little weight though she claims she has cut back on her eating. As you are about the leave the exam room, she says that for the last several months she has been felt some numbness and discomfort in her anterior thigh. She denies any weakness or numbness elsewhere
Differential diagnosis? 4
.1 Meralgia paresthetica- Lateral femoral cutaneous nerve
- Nerve root irritation- L2, L3
- Hip joint arthritis - groin pain
4 Multiple sclerosis
I keep stubbing my toe
A very active 45 year old business woman who likes to run, bike and ski comes in complaining that for the last several months she has stubbed her right toe on multiple occasions. This has even caused her to fall. She is not entirely sure when it started and feels it may be getting worse. She sprained her ankle several months ago.
Differential diagnosis? 4
- peroneal nerve palsy
- ankle sprain, knee dislocation
- L4,5 Disc
- ant tib compartment syndrome
Peroneal nerve palsy signs and symtpoms?4
Diagnosis? 2
Treatment? 2
S/S
1.
- foot drop,
- slapping gait
- Tinel’s sign,
- dec’d sensation first web space
Dx
2.
- clinical exam,
- EMG at 1 month
Rx
3.
- drop foot brace, 80% recover
- occasionally need surgery
I am really beat
35 year old man who works as a computer programmer comes in because of increasing difficulty getting up and down stairs. He feels tired all the time. He finds it tiring to talk for any prolonged period of time. His general health is good. He has had to stop running and lifting weights.
Differential Diagnosis? 6
- Myasthenia gravis
- Thyroid disease
- Diabetes
- Lupus
- Demyelinating CNS
- Anemia
- Work up for myasthenia gravis? 2
- Treatment? 1
- Pathophysiology?
- HOw do we know this isnt Bell’s palsy?
- W-U
- blood for antibodies
- EMG - Rx
- ACTH inhibitors
immunosuppressants
3.
ng antibodies that block acetylcholine receptors at the postsynaptic neuromuscular junction,[1] inhibiting the excitatory effects of the neurotransmitter acetylcholine on nicotinic receptors at neuromuscular junctions. So DX is myasthenia gravis
- No mouth droop – have forehead wrinkling
My handwriting is poor
65 year old house wife comes in complaining that her hand-writing has gotten poor. She has also noted that her grip is weak and her hand will wake her up at night with numbness and tingling. Her other hand does not give her much trouble
Differential Diagnosis? 4
- carpal tunnel syndrome
- hand arthritis
- tremors
- ADHD
He’s never been right
A mother brings her three year old to the office for a routine visit. He was born a month prematurely after a complicated labor. He is behind on his developmental mile stones and has trouble walking, speaking and manipulating fine objects. On exam you find his motions are not well-coordinated and his lower extremities are mildly spastic.
What are the types of this and describe them? 5
What are the treatments? 5
See picture
- PT,
- OT,
- braces,
- assistive devices,
- speech therapy – occasionally surgery
