Transcript Chapters 21-24

Harrison’s
BookClub
Club
Harrison’s Book
Session Three
Chapters 21-24
9/15/05
Chapter 21 – Weakness , Movement, Imbalance
Which of the following statements is incorrect?
A) Fasiculations help differentiate lower motor neuron
disease from myopathy.
B) Flaccidity (or weakness with decreased tone) is caused
by disease of the motor units.
C)Rigidity is increased tone, and is always present with
upper motor neuron disease.
D)Babinski’s sign indicates upper motor neuron disease.
E) Absent deep tendon reflexes most likely represent
upper motor neuron disease.
Chapter 21 – Weakness , Movement, Imbalance
UMN & LMN Disease
• Clasp-knife phenomenon reflects
spasticity affecting antigravity muscles
showing UMN disease --- T or F
• Lead-pipe stiffness affects flexors more
than the extensors occurring commonly in
the involvement of the pyrimidal tract
T or F
Chapter 21 – Weakness , Movement, Imbalance
Paratonia- increased tone that
varies irregularly
• Gegenhalten (paratonia) usually results
from disease of the temporal lobe
T or F
Chapter 21 – Weakness , Movement, Imbalance
UMN Disease
• Fasciculations is commonly seen in UMN
disease
• Is associated with absent Babinski’s
• Tone is spastic
T or F
Chapter 21 – Weakness , Movement, Imbalance
Hemibellismus
• Due to infarction of the contra-lateral
thalamic nucleus T or F
Chapter 22 – Numbness, Tingling, Sensory Loss
CC: “ Both of my legs hurt “
HPI: A 58 y/o AAM with a history of High blood pressure,
non- insulino dependent Diabetes,
Hypercholesterolemia, CAD s/p CABG, CHF,
Pacemaker AICD implantation and Right Carotid
Endarterectomy is brought on to your office by his wife
because , for the past 2-3 weeks, both of his legs are
hurting . The man describes a severe leg pain that
comes on after walking about 4 city blocks. His
exercise tolerance has some variability. However, the
patient initially noted the onset of numbness, tingling
and weakness in the legs while walking downhill.
Chapter 22 – Numbness, Tingling, Sensory Loss
He has started sitting at bus stops waiting for the pain to
resolve and then walking to the next bus stop where he
would again stop for a rest. The numbness and tingling
increase as he walks. The patient recalls only mild ,
low back pain that he has had for a number of years
and some intermittent nocturnal bilateral foot
cramping.
ROS: As per HPI . All other systems are negative. There
is no change in bowel, bladder or sexual function.
PMH : HTN, DM, Hypercholesterolemia, CAD, CHF.
PSH: CABG in 1996, Endarterectomy in 1998 , AICD
placement in 2000.
Chapter 22 – Numbness, Tingling, Sensory Loss
SH: 40 pack years, Occasional drinker and No history of
IVDA
Fam Hx: HTN , Diabetes ( Mother)
Medications: Aspirin 325mg, Lopressor 50mg twice daily,
Vasotec 20mg daily, Lasix 40mg daily, Zocor 40mg
daily , Glipizide 5mg daily and Glucophage 500mg
twice daily.
Chapter 22 – Numbness, Tingling, Sensory Loss
Physical Examination :
Vitals: Temp 98, Pulse 60, Resp Rate 18 , BP 148/82.
General Appearance: Overweight
HEENT: No JVD, No carotid bruit , Thyroid not palpable ,
No Lymph nodes
CVS: Regular Heart Rhythm, S1+S2 , No murmur, No
gallop, Peripheral Pulses present and symmetrical.
Lungs: Clear, No wheezes , No Rales
Abdo: Soft , Non tender, BS X4 , No Organomegaly
Neuro: CN II – XII intact , No Focal Neurologic Deficit,
Normal strength and tone, Straight leg Raising test
negative, DTR absent in the recumbent position but
present when sitting up in the lower extremities.
Chapter 22 – Numbness, Tingling, Sensory Loss
LABS: Hb 10.9, HCT 39.8, MCV 89,WBC 7000/mm3,
Platelets 234.0000/mm3, Na+ 142, K+ 3.3, CL- 112,
Bicarbonate 26, BUN 27, Creat 1.3, Glucose 152,
Ca2+ 8.2 , Phosphorus 3.5 , Mg2+ 2.2 , Protein 5.5.
Chest X ray : Cardiomegaly. No CHF. Pacemaker.
EKG: Pacemaker drive
Chapter 22 – Numbness, Tingling, Sensory Loss
1) What is the next best step in the management of this
patient?
a) X ray of the spine
b) Correction of Electrolytes abnormalities
c) Arterial duplex of lower extremities
d) Ankle-brachial blood pressure ratio
e) CT scan of the spine with contrast
f) MRI of the spine
g) Electromyography
Chapter 22 – Numbness, Tingling, Sensory Loss
2. What is the most likely diagnosis ?
a) Tumor involving the cauda Equina
b) Herniated Disc
c) Peripheral Vascular disease
d) Lumbar spinal stenosis
e) E. Bilateral Sciatica
3. What is the best test in the diagnosis of the
suspected condition in this particular patient?
a) Protein Electrophoresis
b) Electromyography of the lower extremities
c) Arteriography
d) MRI of the spine
e) CT Myelography .
Chapter 22 – Numbness, Tingling, Sensory Loss
4) What is the most sensitive location to test an L5
sensory deficit ?
a) Heel
b) Medial foot
c) Great toe
d) Lateral foot
e) Anterolateral calf
f) Lateral malleolus
Chapter 23 – Aphasia, Memory Loss
Which of the following lesions is incorrectly paired with
the clinical syndrome?
a)
b)
c)
d)
e)
a tumor causing damage to the hippocampus and entorhinal
cortex in a patient who cannot remember what he did yesterday
an embolus to the inferior division of the MCA in a patient who
cannot understand simple questions and cannot meaningfully
express her thoughts
infarction of the anterior perisylvian and insular cortex in a
patient who is frustrated and tearful because he cannot speak
fluently
a tumor in the posterior perisylvian region in a patient with poor
performance on the digit span and who is mistaken to be manic
damage to the inferior parietal lobule and angular gyrus in a
patient who cannot perform simple arithmetic, has trouble
writing, and cannot distinguish between her right and left foot
Chapter 23 – Aphasia, Memory Loss
a)
b)
c)
d)
e)
typical lesion of limbic system causing retrograde amnesia
typical lesion for Wernicke’s area in a patient with impaired
comprehension
typical lesion for Broca’s area in a patient with decreased
fluency
CORRECT ANSWER: describes a lesion to Wernicke’s area but
syndrome consistent with frontal lobe disease
typical lesion for patient with Gerstmann’s syndrome
Chapter 24 – Sleep Disorders
A 36 year old African American woman came in with a
chief complaint of unrefreshed sleep, excessive
daytime sleepiness that was getting worse and
interfering with her work. On physical examination:
BP: 150/80 PR: 92/min RR: 15/min T: 99.6F BMI: 32
warm dry skin
pink palpebral conjunctiva, pupils 2-3mmERTL
moist buccal mucosa with enlarged tonsils R>L Oropharynx:
Malampati class III
supple neck with no palpable lymph nodes nor nexk masses
Symmetrical chest expansion, clear breath sounds
Apex beat at 5th LICS AAL, normal S1, S2 with prominent P2
soft flabby abdomen NABS, (-) hepatosplenomegaly
extremities pulses full and equal
Chapter 24 – Sleep Disorders
Which of the following pathophysiologic mechanism does
not explain the cardiac findings on this patient?
a. acute Co2 retention causing chronic hypoventilation
and subsequesntly pulmonary vasoconstriction
b. Increase pleural pressure that causes an increase
afterload causing systemic hypertension
c. systemic vasoconstriction causing systemic
hypertension
d. pulmonary vasoconstriction thereby causing pulmonary
hypertension
Answers
Chapter – 21
21
(T, F), (F), (F,F,T), (T) – Dr. Faraz
C
Dr. Locke
Chapter – 22
D,D,E,C
Dr. Tchokonte
Chapter – 23
D
Dr. Hakim
Chapter – 24
B
Dr. Go