Acute limb weakness

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  • Created by: z
  • Created on: 13-03-16 19:15

UMN vs LMS lesion

  • UMN
    • increased tone/spasticity
    • brisk reflexes and clonus
    • weakness- NO wasting
    • upgoing plantars
  • LMN
    • reduced tone (flaccid)
    • reduced/absent reflexes
    • weakness with wasting, fasciculations
    • downwards (normal) plantars
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Weakness

  • duration
    • acute (e.g. stroke)
    • sub-acute
    • chronic
    • acute0on-chronic (e.g. relapsing/remitting MS)
  • localisation
    • unilateral
    • bilateral
    • proximal (think myopathy)
    • distal (peripheral neuropathy)
  • age
  • FHx (genetic)
  • sex & race
  • otehr health problems, medication
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Lacunar infarction case

  • history
    • 72M fell to ground when trying to get out of bed
    • developed weakness in R arm and leg
    • HTN for many years
  • examination
    • RS facial weakness w/ forehead sparring
    • speech mildly slurred
    • R arm and leg flaccid w/ brisk reflexes
    • R plantar response was extensor (upgoing)
    • RS mild reduction in pinprick sensation 
  • acute, HTN Hx, unilat, UMN signs, flaccid, CNv involvement (NB Cran nv=brain affected)
    • many things affected: vascular
    • Dx=spinal shock secondary to lacunar infarction 
      • acute, flaccid paralysis w/ loss of sensation w/ gradual dvlpmt of spasticity + recovery of reflexes
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Space occupying lesion case

  • history
    • 72M progressive weakness of R arm and leg over 6/12
    • HTN for many years
  • examination
    • RS facial weakness w/ forehead sparing
    • speech mildly slurred
    • R arm and leg ******* w/ brisk reflexes
    • R plantar upgoing
    • RS mild reduction in pinprick sensation
  • chronic, unilat, HTN, UMN, CNv,
    • Dx= space occupying lesion- left sided
    • dd > primary brain tumour, secondary brian tumour, abscess, chronic subdural haemotoma
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cervical spondylosis case

  • Hx
    • 65M
    • tingling in fingers w/ weakness in hands over 6/12
    • difficulty walking, tendency to catch feet over 2/12
    • neck pain for many years
  • Ex
    • weakness in biceps and forearm, wrist extensors and flexors, small m of hands
    • biceps and brachioradialis reflex absent, others v brisk
    • plantar upgoing
    • incr tone in lower limbs
    • reduced pinprick sensation in hands and arms
  • chronic, bilateral, specific weakness pattern, specific reflexes absent, neck pain, UMN
    • cervical spondylosis causing radiculomyelopathy
      • NB pyramidal weakness- antigravity m. weaker (normally stronger)
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MND case

  • Hx
    • 65M
    • progressive weakness in both hands over 6/12
    • difficulty in walking and foot drag over 2/12
    • speech difficulties
  • Ex
    • global weakness, watsing and fasciculation in both upper limbs more prominent in small m. of hands
    • incr tone in lower limbs
    • all reflexes brisk and upgoin plantars
    • no snesory abnormalities
  • chronic, bilat, speech difficulties,UMN + LMN signs, no sensory signs
    • Dx - motor neurone disease
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Compressive lesion case

  • Hx
    • 65M
    • 15/7 weakness in both legs and back pain
  • Ex
    • mod weakness in both lower limb, more prominent in flexor muscles
    • reflexes brisk, upgoing plantars, reduction of pinprick snesation below umbilicus
  • key points
    • sub-acute, bilat, weakness in flexors, UMN signs, sensory reduction
  • Dx
    • compressive lesion - tumour around T10
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Ischaemic cord case

  • Hx
    • 72M
    • sudden onset weakness in both legs after AA stent
  • Ex
    • flaccid weakness in both lower limb
    • reflexes depresses, upgoin plantars
    • reduction of pinprick sensation up to level of umbilicus
  • key points
    • acute, bilateral, flaccid, upgoing plantar, sensory level
  • Dx
    • ischaemic cord 
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Transverse myelitis case

  • Hx
    • 44F
    • 3/7 progressive weakness inboth limbs
    • acute mid-dorsal pain ~30mins at onset
    • 1/7 dicturbance of bladder func
    • numbness and tingling in limbs
    • 2/52 ago had mild URTI
  • E
    • severe flaccid paralysis in both lower limbs w/ depressed reflexes
    • plantars upgoing
    • reductaion in pinprick sensation up to umbilicus
    • bladder palpable at umbilicus
  • key points- acute, bilat, pain, URTI, sensory level, spinal shock signs
  • Dx- transverse myelitis (inflammatory)
    • MS most common cause, viral 2nd 
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Guillain barre syndrome case

  • Hx
    • 44F
    • 1/52 progressiv eweakness in both lower limbs spread to involve upper limbs
    • numbness and tingling in limbs
    • 4/52 before onset had flu-like illness
  • Ex
    • not able to walk independently
    • generalised m. weakness, reduced tone and absent weakness in all limbs
    • plantars downgoing
    • reduction in pinprick sensation below level of knees
  • key points- acute, bilat, flu-like illness, LMN, mild sensory, ascending
  • Dx - Guillain Barre syndrome
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Spinal cord diseases

  • acute
    • vascular (infarc, haemorrhage)
    • transverse myelitis (viral, MS, inflammatory)
  • chronic
    • disc disease
    • inflammatory (MS, sarcoid),
    • spinal tumours
    • hereditary
    • B12 deficiency
    • vascular (AVM)
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charcot marie tooth case

  • Hx
    • 55M
    • 15yr progressive weakness o fm of feet and calves
    • 10yr of sim in hands
    • mother has same
  • Ex
    • distal weakness and watsing in upper and lower limbs
    • absent reflexes in all limbs
    • plantar reflexes downgoing
    • mild distal sensory loss
  • key points - chronci. bilat, distal, mild sensory symp, LMN signs, FHx
  • Dx- Charcot-Marie-Tooth (CMT)
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Peripheral neuropathy causes

  • congenital (CMT)
  • metabolic (B12 def)
  • toxic (alcohol ,drugs)
  • endocrine (DM, thyroid)
  • inflammatory (GBS)
  • neoplastic (paraneoplastci)
  • infective (HIV. Lyme)
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Proximal myopathy case

  • Hx
    • 55M
    • 12/12 progressiv edifficulties in standing up from sititng
    • 15yr RA
    • long term prednisolone, methotrexate
  • Ex
    • moderate weakness proximal lower and upper limbs
    • normal reflex all limbs
    • planras downgoing
    • no sensory loss
  • key point - chronic, bilat, RA, steroids, methotexate, proximal weakness, no sensory 
  • Dx - proximal myopathy due to steroids
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Myopathy causes

  • congenital
    • muscular dystrophies
    • metabolic disorders
    • mitochondrial myopathies
  • acquired
    • metabolic (osteomalacia0
    • endocrine (thyroid, Cushing's)
    • toxic (drugs, alcohol)
    • inflammatory (polymyositis)
    • neoplastic (paraneoplastic)
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