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
My head hurts
60 y/o male diabetic, with
hypertension, and A-fib
comes to the ER with an hour
history of headache, facial
weakness, and confusion. He is
having trouble moving his left
arm and leg. For the last month
he has had intermittent episodes
of numbness and tingling
in his face and problems
remembering words.
Differential Diagnosis? 6
- Stroke - CVA
- Seizure,
- migraine aura,
- tumors,
- hematomas,
- Bell’s palsy
60 y/o male diabetic, with
hypertension, and A-fib
comes to the ER with an hour
history of headache, facial
weakness, and confusion. He is
having trouble moving his left
arm and leg. For the last month
he has had intermittent episodes
of numbness and tingling
in his face and problems
remembering words.
- What type of stroke?
probably ischemic
embolic or occlusive?
- Workup? 2
- Treatment?
- occlusive
- head CT and coagulation studies
- fibrinolytics
My feet hurt
A 70 year old lady comes in complaining that both her feet are hurting her. She feels this started two or three months ago. Her general health is good. She does a lot quilting and scrap booking. The pain is worse when standing and doing her housework.
Differential? 5
Treatment? 2
DDx
- OA RA
- Gout
- Morton’s neuroma
- Plantar fascitis
- neuropathy
Rx - Mortons neuroma
- Fusion 1st MP joint
- special shoes
My hands keep shaking
A 60 year old banker comes in complaining that for the last several months his hand keeps shaking. His general health is good but he finds that he can not do things as quickly as he used to. You observe that his gait is wide-based and that he sways as he walks.
Differential? 2
Treatment? 2
- Parkinsons
- Essential tumor
Parkinson’s L-Dopa
Essential tremor B-blockers
I can’t walk in heels anymore
A 55 y/o woman comes in because she is having trouble walking in heels. Two months ago twisted her right ankle. She felt a pop about the medial side of her ankle and thinks she later developed a bruise there . She saw her PCP who felt she had sprained her ankle. On exam she is unable to stand on tip toe on the right. She notes aching discomfort about the medial side of her ankle
Differential Dx? 5
Treatment? 2
1. Posterior tibial tendon rupture
2. Achilles rupture
3. Loss of proprioception
4. polyneuropathy
5. nerve root lesion, L4-5
RX tendon rupture
1. arch supports occasionally sufficient
2. usually need surgery
He has an ulcer on his foot
An 80 y/o man is sent to your office from the nursing home after one of the patient care aides saw this ulcer on his foot. The patient was not aware of it. He is somewhat confused but apparently it does not cause him any pain. He is afebrile.
Differential Dx? 6
Treatment?
- polyneuropathy – diabetic most common
- liver failure,
- kidney failure,
- hypothyroidism
- drugs, xs vitamin B6, alcohol, B12 deficiency
- inflammatory diseases (Guillan Barre)
Rx for polyneuropathy
- protect from pressure, debride and drain,
- antibiotics, management of diabetes, wound vac,
- hyperbaric oxygen – may come to amputation
She can’t move her arm
A four year old is brought in by her father because she has not been able to use her left arm for the last two days. She has no other weakness and sensation is intact. She had a mild URI a week ago. Her brother (bottom right) has no problems.
Differential Dx? 5
Treatment? 3
- enterovirus-68
similar to polio – anterior horn cells
- West Nile,
- echoviruses,
- adenoviruses
- nursemaid’s elbow
RX
- none for the disease
- bracing,
- surgery for function
Im in a mess
You are called to the emergency room to see one of your long term patients who has come in because of back pain, trouble controlling his legs, numbness in his inner thighs, and incontinence. He is 65 and has been in good health. He recently retired and has just spent the last three weeks on a safari in Africa. He has mild hypertension and moderate glaucoma.
Differential Dx? 7
Symptoms? 4
Treatment? 1
- Cauda equina syndrome
- tumors,
- trauma,
- spinal stenosis,
- herniated disc******
- inflammatory diseases,
- post back surgery
Symptoms?
- Back pain,
- saddle anesthesia,
- bowel/bladder problems,
- leg weakness
RX: surgery
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
He’s having toruble going up the stairs
You are working in a pediatric office when a worried mother brings in her 4 year old boy. For the last several months she has noticed that he is not as active as before, he seems to have trouble going up stairs, and sometimes even has trouble getting up from the ground. His general health is good, no recent illnesses, and his immunizations are up to date.
Diagnosis? 1
How to make the diagnosis? 2
Treatment? 6
- Muscular dystrophy
- Dx BX, EMG
Rx
- PT,
- OT,
- bracing
- surgery – scoliosis
- Anitsense therapy
- oligonucleotidesligonucleotide
for genetic disorders
inactivates the gene
My arm is killing me
A 45 year old housewife comes in because of severe right arm and hand pain. 6 weeks ago she fell and sustained a minimally displaced wrist Fx. She was treated in a cast. A week later she developed severe burning pain in her hand and arm. Her hand and fingers have become quite swollen. She is having using her hand and it it is quite cold. X-rays show her fracture has healed. Her pain is not relieved with narcotics.
- Diagnosis?
- What kind of dysfunction?
- symtpoms? 3
- REFLEX SYMPATHETIC DYSTROPHY
- ANS dysfunction
3.
- pain
- swelling
- loss of circulation
I can’t move my arms and legs
45 year old roofer falls off the second story of a house he is shingling, landing on his neck and shoulders in a flexed position. He puts his feet down to get up and suddenly finds he can’t move. He is brought to the emergency room where you see him.
Diagnosis? 2
traumatic quadriplegia
complete or incomplete
What is anterior cord syndrome? (what kind of injury and loss of?3)
What is central cord syndrome? (what kind of injury 2 and loss of? 2)
What is Brown-sequard syndrome? (what kind of injury and what kind of losses? 2)
ANTERIOR CORD SYNDROME
- FLEXION INJURIES
- LOSE MOTOR, PAIN, TEMP
CENTRAL CORD SYNDROME
- ISCHEMIA, HEMORRHAGE
- UPPER EXTREMITIES EFFECTED
MORE THAN LOWER
‘REVERSE PARAPLEGIA’
BROWN-SEQUARD SYNDROME
- PENETRATING INJURY ONE SIDE
- LOSE MOTOR THAT SIDE
MIXED SENSORY LOSS
What do you lose on the same side in Brown Sequard? 5
Opposite sides? 3
BROWN SEQUARD
Same side lose:
- light touch,
- conscious proprioception,
- vibration,
- pressure
- 2-point discrimination,
Opposite side lose:
- pain,
- temperature sensation
- crude touch
Biceps ? - Brachioradialis ? - Triceps ? - Patella ? - Ankle?
- C5-6
- C6
- C7-8
- L2-4
- S1-2
Symptoms of Lower motor injuries? 2
flaccid paralysis, loss of DTR
Symptoms of upper motor injuries? 3
lose of inhibition, spasticity and hyperreflexia
Cause of cerebral palsy?
Cause of muscular dystrophy?
Cerebral palsy from perinatal brain damage
Muscular dystrophy from genetic condition causing loss of muscle cells
What are the complete spinal injuries? 2
What is the partial? 3
Complete: quadriplegia, paraplegia
Incomplete: anterior, central, Brown-Sequard
