Question of the day: Neurological exam
November 8th, 2009
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 triceps 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 a comment with your answer… we will let you know the correct answer soon!
Purely motor symptoms therefore should be a disease of the motor neurones, therefore i vote motor neurone disease
Fact
Guillain Barre Syndrome
Guillain Barre Syndrome
motor neuron disease
MuLtiple sClerosis
Lower motor neurone problem, Distal > Proximal, Subacute Onset. Symmetrical, Sensation intact(usually a later onset problem.
Therefore GBS most likely.
Symptoms of a lower motor neurone lesion – reduced tone, areflexia plus a very rapid onset suggests Guillain Barre.
guilian barre syndrome
Motor neurone disease would tend to give a mixed UMN and LMN picture, so my guess is Guillain Barre syndrome
MND
GB
guillia barre syndrome
motor neuron diseas
the case is GBS gullian barre syndrome/ features are / hyporeflexia/ hypotonia
multiple sclerosis
seems to me as a case of motor neuron disease
MND
Guille barre syndrome
Motor weakness, with areflexia and age group
POLIO
GB Syndrome.
motor neuron disease.
MND GBS I’m out of touch slightly.
GBS
motor weakness, absent or decreased reflexes=guillain Barre syndrome
Cannot be Multiple Sclerosis coz you are more likely to see upper motor neurone signs wit hmotor weakness
Stroke causes upper motor neurone features
MND has mixed UMN+LMN signs whereas this man has pure LMN signs
Creutzfeldt Jacob disease would have manifested with myoclonic jerks
Myaesthenia gravis shows worsening function with repeated use of the muscle/muscle group
Thanks for all of the guesses… those of you who suggested Guillain Barre Syndrome were correct!
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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