Numbness/weakness

Question 1

Key history in numbness/weakness

Answer 1

Distribution (unilateral, bilateral, proximal, distal)
Duration
Progression
Pain (e.g. HA, neck or back pain)
Constitutional symptoms
Other neurologic symptoms
Hx of DM, alcoholism, atherosclerosis

Question 2

Key physical exam in numbness/weakness

Answer 2

Vital signs
Neurologic and musculoskeletal exams
Relevant vascular exam

Question 3

68 yo M with 20-minute episode of slurred speech, R facial drooping and numbness, and R hand weakness that are all now resolved
+ PMHx of HTN, DM and heavy smoking

Answer 3

Transient ischemic attack (TIA)
Hypoglycemia
Seizure

CT-head, CBC, electrolytes, glucose, fasting lipid panel, ECG, MRI-brain, Doppler US - carotid, echocardiography, EEG

Question 4

68 yo M with slurred speech, R facial drooping and numbness and R hand weakness
+ Babinski’s sign present on R
+ PMHx of HTN, DM, heavy smoking

Answer 4

Stroke
TIA
Seizure

CT-head, CBC, electrolytes, PT/PTT/INR, fasting lipid panel, MRI-brain, Doppler US - carotid, echocardiography, ECG

Question 5

33 yo F with ascending loss of strength in lower legs over last two weeks
+ recent URI

Answer 5

Guillain-Barre syndrome
Multiple sclerosis
Polymyositis

CBC, electrolytes, CPK, LP-CSF analysis, MRI-spine, EMG, nerve conduction studies, edrophonium test (for myasthenia gravis), serum B12

Question 6

30 yo F with weakness, loss of sensation, tingling in L leg starting this morning
+ R eye pain, decreased vision and double vision
+ “Electric shocks” down spine upon flexing head

Answer 6

Multiple sclerosis
Stroke
Conversion disorder

CBC, ESR, VDRL/RPR, MRI - brain and spine, LP-CSF analysis, retinal evoked potentials

Question 7

55 yo M with tingling and numbness in hands and feet (glove-and-stocking distribution) over last two months
+ Hx of DM, HTN, alcoholism
+ Decreased soft touch, vibratory and position sense in feet

Answer 7

Diabetic peripheral neuropathy
Alcoholic peripheral neuropathy
B12 deficiency

HbA1c, ESR, calcium, serum B12, UA, serum and urine protein electrophoresis (for multiple myeloma)

Question 8

40 yo F with occasional double vision, droopy eyelids at night with improvement by morning

Answer 8

Myasthenia gravis
Horner’s syndrome
Multiple sclerosis

Edrophonium test (for myasthenia gravis), serum ACh receptor antibodies, CXR, CT-chest, MRI-brain, EMG

Question 9

25 yo M with hemiparesis after tonic-clonic seizure that resolved after a few hours

Answer 9

Todd’s paralysis
TIA
Stroke

CBC, electrolytes, EEG, MRI-brain, Doppler US - carotid

Question 10

56 yo obese F with constant tingling and numbness of thumb, index finger and middle finger (median nerve distribution) worsening over last five months
+ works as a secretary
+ Hx of fatigue and 20 pound weight gain over same period

Answer 10

Carpal tunnel syndrome secondary to hypothyroidism
Overuse injury of median nerve
Medial epicondylitis

Phalen’s maneuver and Tinel’s sign
Nerve conduction studies
TSH
CBC