Weaknesses: a clinical approach Flashcards
What are the different types of weakness?
acute
chronic
sub-acute
acute-on-chronic
Case 1:
- 72 M fell in the morning getting out of bed
- weakness in R arm and leg
- treated many years for hypertension
- O/E R sided facial weakness spared the forehead, mildly slurred speech, hypertonia in R arm and leg, hyperreflexia, R plantar response was extensor, mild reduction in pinprick
What is the diagnosis?
acute, unilateral, hypertension, cranial nerve involvement
UMN signs
=> vascular lacunar infarct
Case 2:
- 72 M progressive weakness in R arm and leg over 6 months
- treated hypertension for years
- O/E R sided facial weakness spared forehead, mildly slurred speech, R arm and leg were spastic with hyperreflexia, R plantar response was extensor, mild reduction in pinprick sensation
What is the diagnosis?
chronic, unilateral, hypertension, cranial nerve involvement, UMN signs
Space occupying lesion - most likely a cortical lesion on the L side of the brain above the pons
What can be the cause of a space occupying lesion?
primary brain tumor
secondary brain tumor
abscess
chronic subdural haemotoma
Case 3:
- 65 M tingling in fingers with weakness of hands over period of 6 months
- difficulty walking and tendency to catch feet over 2 month periods
- neck pain for some years
- O/E weakness in biceps and forearm and wrist extensors and flexors and hand muscles, absent biceps and brachioradialis reflexes, others very brisk, plantar were upping, hypertonia of lower limbs, reduced pinprick sensation over forearm and hands
What is the diagnosis ?
chronic, bilateral, specific reflex patterns, UMN signs
cervical 5/6 lesion - caused by cervical spondylosis causing radiculomyopathy
Case 4:
- 65 M progressive weakness of both hands over 6 month period
- difficulty walking and tendency to drag feet
- speech difficulties
- O/E global weakness, wasting and fasciculations in both upper limbs, prominent in small hand muscles, hypertonia in lower limbs, brisk reflexes and both plantar responses upping, no sensory abnormalities
What is the diagnosis?
chronic, bilateral, mixed UMN and LMN signs, no sensory signs, speech symptoms
Motor neurons disease
Case 5:
- 65 M 15 day hx of weakness in both legs and back pain
- O/E moderate weakness in both lower limbs, reflexes brisk with upping plantar, reduction of pin prick sensation up to umbilicus (T10)
What is the diagnosis?
subacute, bilateral, UMN signs, sensory level
Lesion spinal cord T10 = compressive lesion … tumor?
Case 6:
- 72 M sudden onset weakness in both legs after stinting of an aortic aneurysm
- O/E flaccid weakness in both lower limb, hyporeflexia, upping plantar, reduced pin prick sensation at level of umbilicus (T10)
What is the diagnosis?
Acute, bilateral, sensory level, flaccid, reflexes depressed, upgoing plantar
Lesion at t10 sc - vascular ischemia
- supposed to be LMN signs yet they have UMN damage and this is due to spinal shock => motor (flaccid paralysis) with loss of sensation with gradual development of spasticity and recovery of reflexes
Case 7:
- 44 F 3 day hx of progressive both lower limb weakness
- acute dorsal pain lasting about 30 mins
- day before had disturbance of bladder function
- numbness and tingling in limbs
- 2 week before mild URTI
- O/E severe flaccid paralysis both lower limbs with depressed reflexes, plantar reflexes were upping, reduction in pinprick sensation over lower limbs up to umbilicus, urinary bladder palpable
What is the diagnosis ?
acute, bilateral, pain, URTI, sensory level
SC lesion around t10 => transverse myelitis= inflammation of the SC commonly caused by viral infection
Case 8:
- 44 F 1 week hx progressive weakness in both lower limbs spread to involve upper limbs
- numbness and tingling in her limbs
- 4 weeks before she had flu like symptoms
- O/E unable to walk independently, generalized muscle weakness, reduced tone, absent reflexes, plantar reflexes were downing, reduced pinprick sensation below knee
What is the diagnosis?
Acute, bilateral, mild sensory symptoms and signs, LMN signs, URTI
- Guillian barre syndrome = inflammation of the nerve roots= predominantly motor symptoms
What are the causes of peripheral neuropathy?
congenital = CMT metabolic = B12 deficiency Toxic = alcohol, drugs Endocrine = DM, thyroid disease Inflammatory = GBS Neoplastic = most paraneoplastic Infective = HIV, lymes disease
Case 9:
- 55 M 10 month hx numbness and tingling in both feet
- 10 year hx DM
- O/E reduction in pinprick sensation in stocking distribution, ankle jerks absent, impairment of vibration and proprioception
What is the diagnosis?
Subacute/chronic Bilateral Lower limb Distal DM
Sensory peripheral neuropathy due to DM
Case 10
- 35 F 3 month hx of variable double vision and droopy eyes
- difficulty climbing stairs and putting things on high shelves
- worse in evenings and easily fatigued
- O/E bilateral asymmetrical ptosis, variable ophthalmoplegia, fatiguable proximal weakness
What is the diagnosis?
subacute, bilateral, eyes, proximal weakness, fatiguability
Myasthenia gravis = AchR blocked by antibodies
Case 11
- 55 F 12 month hx of progressive difficulties standing out of chair/toilet
- 15 year hx RA and long-term tx with low dose prednisolone and methotrexate
- O/E moderate weakness proximally in both lower and upper limbs, normal reflexes in all limbs, plantar reflexes were downing and no sensory loss
What is the diagnosis?
chronic, bilateral, no sensory symptoms and signs, specific weakness patterns, long term treatment with low dose pred
proximal myopathy caused by steroid use
What are different types of myopathies?
congenital
- muscular dystrophies
- metabolic disorders
- mitochondrial myopathies
Acquired
- metabolic (osteomalacia)
- endocrine (thyroid disease)
- toxic (alcohol, drugs)
- inflammatory (polymyositis)
- neoplastic
