January 30th, 2012
We asked you about this case of a 37 year old intravenous drug user with suspected bells palsy.
And after reading his case, the diagnosis is:
d. Ramsay Hunt Syndrome
Firstly this is a lower motor neuron (LMN) facial (CN VII) palsy: facial weakness of the whole of the face.*
Bell’s is a lower motor neurone lesion which is idiopathic in nature.
The aetiology is probably thought to be a herpes virus and there is some evidence to support the use of short course oral corticosteroids and aciclovir.
- about 50% of people will get better with no treatment
- steroids for approximately 1 week seem to help 50% of cases
- the benefit of aciclovir remains controversial
Read the Bandoleir review here
However: Ramsay Hunt is a facial nerve palsy caused by associated herpes zoster infection (as manifested in this case by the vesicles). When a patient presents with a CNVII weakness, this is one of the key reasons to perform otoscopy, as otherwise you may miss the vesicles.
*Remember in UMN lesions the upper half of the face (highlighted here in yellow) is spared as there is bilateral UMN innervation. You would not expect this in Ramsay hunt as its a LMN lesion. The image below shows a LMN CNVII weakness.
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October 20th, 2011
Well done to those who answered correctly, and comisserations tho those who got caught out… the correct answer to this question was:
g. Guillain Barre Syndrome
See why it was Guillain Barre Syndrome below. Check your hypothesis against the clinical signs:
| Tone |
any sign of UMN lesion or hypotonia (cerebellar?) NO
but there is some reduced tone in the left arm: |
| Power |
He is weak and its come on over the past few days: this is classical of GBS: an ascending peripheral motor and sensory poylneuropathy. |
| Coordination |
Normal: as expected |
| Sensation |
Normal: So can it still be GBS???
YES! The sensory signs are often vary vague: there may be only back pain as the presenting feature. |
| Reflexes |
Clinical tip: no reflexes suggests a lower motor neurone problem. Could it me MND? Very unlikely: there’s only LMN signs and the onset of the illness is too acute. |
| Other things |
GBS: measure the Forced Vital Capacity:
If this is low: the patient may need ventilation.
Also remember: cardiac conduction deficits (monitor the patient on a cardiac monitor) |
Remember FVC monitoring in GBS.
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September 21st, 2011
A 44 year old builder presents with weakness over the past 48 hours.
A neurological exam reveals the following (N=normal):
|
Upper Limbs
|
|
|
Lower Limbs
|
|
|
Right
|
Left
|
|
Right
|
Left
|
|
Tone
|
N
|
reduced
|
|
N
|
N
|
|
Power (MRC)
|
4/5
|
4/5
|
|
3/5
|
4/5
|
|
Coordination
|
N
|
N
|
|
N
|
N
|
|
Sensation
Fine touch
Proprioception
|
N
N
|
N
N
|
|
N
N
|
N
N
|
|
Reflexes Biceps
Reflexes triceps
Reflexes supinator
|
- (absent)
- (absent)
+
|
- (absent)
- (absent)
+ with reinforcement
|
Knee
Ankle
Plantar
|
- (absent)
- (absent)
down
|
- (absent)
- (absent)
down
|
Which of the following is the most likely diagnosis?
a. Polio
b. Motor Neurone disease
c. Myasthenia gravis
d. Stroke
e. Multiple sclerosis
f. Creutzfeldt Jacob disease
g. Guillain Barre Syndrome
Leave your answers as comments, and we will give you the full professional medical answer in a few days!
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July 13th, 2011
And here is is…. the answer to our suspected DVT question:
d. It can be used to discharge patients based on their underlying estimated clinical risk score
D-dimer test can be used to exclude DVT in patients who are assessed to be in the category of “low clinical risk” of DVT.
An individuals pre-test risk can be estimated using a “Wells score”. A patient who is clinically “low risk” with a negative D dimmer can be reassured.
The Wells score is shown below.
| Active Cancer |
+1 |
| Paralysis Paresis or plaster to extremity |
+1 |
| Bedridden for 3 days/ surgery within last 12 weeks |
+1 |
| Localised tenderness along distribution of deep venous system |
+1 |
| Entire leg swollen |
+1 |
| Calf swelling >3cm compared to the other leg |
+1 |
| Pitting oedema confined to the symptomatic leg |
+1 |
| Previous DVT |
+1 |
| Collateral superficial veins (non-varicose) |
+1 |
| Alternative diagnosis at least as likely as DVT |
-2 |
| <0=Low Pre-test Probability
1-2=Moderate Pre-test Probability
>3=High pre-test probability |
Check D-dimer
Check D-dimer
DO ULTRASOUND |
The Wells score and an example of its clinical application in terms of planning investigations into a DVT
Although you clearly can’t memorise a wells score its clear from the score itself that patients with numerous risk factors (e.g a man with lung cancer with a swollen right leg with pitting oedema) that a negative D-dimer is not sensitive enough to rule the diagnosis out.
D-dimer is still of some use in patients with a low pre-test probability score.
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July 2nd, 2011
A 62 year old man presents with a swollen right calf 3 weeks after undergoing a total left hip replacement. He is known to have rheumatoid arthritis.
An Emergency Department doctor tells you that he feels the patient can be discharged. He tells you this because he shows you the D-Dimer result, which is “negative”. The result is shown below.
| D-Dimer 0.08 (Normal range 0-0.18) |
Which of the following statements is true about D-Dimer testing in general patients with a suspected DVT?
a. Following a clinical assessment, clinicians should not rely on the test as a basis to ‘discharge’ or ‘investigate’
b. It is of no use in patients who have had recent surgery (e.g. within the last 12 weeks)
c. It is of no clinical use in patients with malignancy and secondary metastases
d. It can be used to discharge patients based on their underlying estimated clinical risk score
e. None of the listed answers are correct.
Leave a comment; answer in a few days!