Weakness

Question 1

Which of the following is NOT on the differential for BILATERAL muscle weakness?
A. Guillain-Barre Syndrome
B. Bells Palsy
C. Lyme disease
D. Myositis

Answer 1

B. Bells Palsy presents asymmetrically

Also asymmetric:
Stroke, nerve compression, trauma

Also bilateral:
Heavy metal, myasthenia

Question 2

Botulism, diptheria, tetanus, heavy metal, Guillain Barre Syndrome present with (bilateral/asymmetric) (distal/proximal) weakness.

Answer 2

Bilateral distal

Question 3

Myasthenia, polymyositis present with (bilateral/asymmetric) (distal/proximal) weakness.

Answer 3

Bilateral proximal

Question 4

Stroke, CNS tumor with (bilateral/asymmetric) (UMN signs/LMN signs) weakness.

Answer 4

Asymmetric, UMN signs

Question 5

Trauma, nerve compression presents with (bilateral/asymmetric) weakness.

Answer 5

asymmetric

Question 6

MS presents with (bilateral/asymmetric) weakness.

Answer 6

asymmetric

Question 7

T/F: Labs are highly telling of the etiology of weakness.

Answer 7

False. Labs aren’t very helpful.

Question 8

Diagnose this!
72 female, right sided weakness both upper and lower extremities, left side moves normally, some left facial droop, weakness bad in morning has been improving, HTN, diabetes, high cholesterol, non-smoker
Exam: Left side facial weakness, CN intact, Reflexes (brisk in right side and normal on left side), sensory intact

Answer 8

ASSESSMENT: Focal, Asymmetric, UMN (brisk reflexes)

DX: Stroke

Question 9

Diagnose this!
35 male, “feels weak all over” getting worse, numbness in both feet a few days ago, numb in hands and feet now, sharp electrical pains, can’t walk or lift legs. ASCENDING PARALYSIS
Exam: CN intact, Motor VERY weak in both lower and upper extremities 1/5), sensory loss in distal extremities, no reflexes, can’t assess gait/balance

Answer 9

ASSESSMENT: Started focal but now more generalized, Bilateral, LMN

DX: Guillain-Barre Syndrome

Question 10

Diagnose this!
22 female, gradually increasing weakness over 2 weeks, feels ok when waking up in the morning but then is exhausted at end of day, last 2 days noted drooping eyelids and diplopia, trouble swallowing, mother has lupus. DESCENDING PARALYSIS
Exam: CN bilateral ptosis, can’t maintain upward gaze, Motor upper extremities 3/5 strength worse on repeated testing, proximal muscle groups more affected, reflexes are weak

Answer 10

ASSESSMENT: Focal, Bilateral, LMN with CN involvement

DX: Myasthenia Gravis

Question 11

Descending paralysis is characteristic of ____

Answer 11

Myasthenia gravis

Question 12

Ascending paralysis is characteristic of ____

Answer 12

Guillain-Barre Syndrome

Question 13

Diagnose this!
68 male, 2 months low back pain, pain radiates down back of right leg, can’t lift right foot, urinary incontinence on/off for last 3 days, prostate cancer
Exam: CN intact, Motor weak right lower extremity (1/5) especially in ankle, Sensory decreased throughout perineum, Reflexes brisk on right side, Gait shows right foot drop, decreased rectal tone (saddle anesthesia)

Answer 13

ASSESSMENT: Focal, Asymmetric (mostly in RL), UMN (brisk reflexes)

DX: Herniated Lumbar Disk (pain radiating down one leg)
AND
Cauda-Equina Syndrome (incontinence, saddle anesthesia)

Question 14

Diagnose this!
37 female, weakness in right leg and left hand, started in numbness in right thigh but now resolved, now has trouble lifting right leg for past week, keeps dropping keys
Exam: CN intact, Motor right lower extremity 3/5 at hip, unable to maintain finger grasp, Sensory decreased along left calf, Gait limp due to weakness on right leg but can stand

Answer 14

ASSESSMENT: Focal, Asymmetric, LMN (reflexes are normal)

DX: Multiple Sclerosis

Question 15

Small diffuse plaques of white matter on MRI is characteristic of ____

Answer 15

Multiple Sclerosis

Question 16

Diagnosis of exclusion, a psychiatric disorder, presents with neural complaint, patient senses dysfunction but its not there, they genuinely feel that something is wrong, when stress goes away, neural discomfort goes away =

Answer 16

Conversion disorder

Question 17

Faking, trying to get something out of it, meds, they know they have a fake disease =

Answer 17

Malingering

Question 18

Diagnose this!
83 male with difficulty walking progressively worse in last 2 months, difficulty alternating movements on right side, ataxia, mild weakness in right arm and leg.

Answer 18

Cerebellum mass

Question 19

Diagnose this!
58 male with peripheral symmetric weakness, works at lead mine
Sensory exam will show stocking/glove neuropathy

Answer 19

Heavy metal?

Question 20

Diagnose this!
35 female with joint pains and facial weakness, shooting back pains, face is “stuck” and can’t smile or raise eyebrows, went camping in Wisconsin 4 months ago

Answer 20

Lyme Disease

WISCONSIN!

Question 21

Diagnose this!
45 male alcoholic, experienced loss of parent and other relative in the same week, last two days unable to stand, falls to right on gait exam, strength in all extremities normal, MRI is normal

Answer 21

Conversion Disorder, Folate Deficiency, Malingering

Question 22

UMN or LMN?

Brisk reflex

Answer 22

UMN

Question 23

UMN or LMN?

Weak reflex

Answer 23

LMN